Basic Information
| Provider Information | |||||||||
| NPI: | 1306074398 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROZER-CHESTER MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104472000 | ||||||||
| FaxNumber: | 6104476620 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 WEST NINTH STREET | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104472000 | ||||||||
| FaxNumber: | 6104476620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6103388225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 037201 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1007605830022 | 05 | PA | MEDICAID |