Basic Information
| Provider Information | |||||||||
| NPI: | 1164581062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID COUNTY SENIOR SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 22 MEDIA LINE RD | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190734601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103536642 | ||||||||
| FaxNumber: | 6103537950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1991 S SPROUT RD | ||||||||
| Address2: | SUITE 850 LAWRENCE PARK ADULT DAY SERVICES | ||||||||
| City: | BROOMALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190083519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103251600 | ||||||||
| FaxNumber: | 6103251495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULIMAY | ||||||||
| AuthorizedOfficialFirstName: | LESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6103536642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | 300140 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 1000058970003 | 05 | PA | MEDICAID | 1000058970007 | 05 | PA | MEDICAID |