Basic Information
Provider Information | |||||||||
NPI: | 1265529705 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CROZER-CHESTER MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CROZERTAYLORSPRINGFIELD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ONE MEDICAL CENTER BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | UPLAND | ||||||||
State: | PA | ||||||||
PostalCode: | 19013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104472000 | ||||||||
FaxNumber: | 6106197331 | ||||||||
Practice Location | |||||||||
Address1: | ONE MEDICAL CENTER BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | UPLAND | ||||||||
State: | PA | ||||||||
PostalCode: | 19013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104472000 | ||||||||
FaxNumber: | 6106197331 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 01/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GAVIN | ||||||||
AuthorizedOfficialFirstName: | PATRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 6103388228 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CROZER/TAYLOR/SPRINGFIELD | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 037201 | PA | Y |   | Hospital Units | Rehabilitation Unit |   |
ID Information
ID | Type | State | Issuer | Description | 1007605830106 | 05 | PA |   | MEDICAID | 135773000 | 01 | PA | MAGELLAN DELCARE | OTHER | 1414 | 01 | PA | AETNA | OTHER | 0001103000 | 01 | PA | IBC/KEYSTONE HEALTH PLAN EAST/AMERIHEALTH | OTHER | 87726 | 01 | PA | UNITED HEALTHCARE | OTHER | 390180 | 01 | PA | AARP | OTHER | 390180 | 01 | PA | TRICARE | OTHER | 60019 | 01 | PA | KEYSTONE MERCY HEALTH PLAN | OTHER |