Basic Information
| Provider Information | |||||||||
| NPI: | 1306285176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HEALTH MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RISING SUN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 MARKET ST | ||||||||
| Address2: | LM 500 WEST TOWER | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191022100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159852500 | ||||||||
| FaxNumber: | 2677652325 | ||||||||
| Practice Location | |||||||||
| Address1: | 5675 N FRONT ST | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152799666 | ||||||||
| FaxNumber: | 2152799674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KILLIAN | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2159852514 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1000016640061 | 05 | PA | MEDICAID |