Basic Information
| Provider Information | |||||||||
| NPI: | 1275968638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENNSYLVANIA HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 WESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080023744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568579387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066500705 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7066500705 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NO11347600 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN616965 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.