Basic Information
| Provider Information | |||||||||
| NPI: | 1164403358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABINGTON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFERSON HEALTH HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 MARYLAND RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154815800 | ||||||||
| FaxNumber: | 2154815850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 MARYLAND RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154815800 | ||||||||
| FaxNumber: | 2154815850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERLIS | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2154815837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ABINGTON MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 714505 | PA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1007691860199 | 05 | PA | MEDICAID |