Basic Information
Provider Information | |||||||||
NPI: | 1225327018 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEAST TREATMENT CENTERS.INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 499 N 5TH ST | ||||||||
Address2: | SUITE A | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191234005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154517000 | ||||||||
FaxNumber: | 2159256897 | ||||||||
Practice Location | |||||||||
Address1: | 5501 CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191393205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154517000 | ||||||||
FaxNumber: | 2154517010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2011 | ||||||||
LastUpdateDate: | 07/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SOLOMONS | ||||||||
AuthorizedOfficialFirstName: | JONATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2154517000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QR0405X | 807359 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 100773886 | 05 | PA |   | MEDICAID | 100773886 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH (CBH) | OTHER | 100773886 | 01 | PA | MAGELLAN HEALTH CHOICES | OTHER |