Basic Information
| Provider Information | |||||||||
| NPI: | 1205954856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE MEDICAL CARE OF PENNSYLVANIA, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1572 WILMINGTON PIKE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193828317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104593278 | ||||||||
| FaxNumber: | 6104598642 | ||||||||
| Practice Location | |||||||||
| Address1: | 1572 WILMINGTON PIKE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193828317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104593278 | ||||||||
| FaxNumber: | 6104598642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 02/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | BRILLIANT | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6104593278 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1018877650001 | 05 | PA | MEDICAID | 1953751 | 01 | PA | BLUE SHIELD | OTHER | 2833384000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER |