Basic Information
| Provider Information | |||||||||
| NPI: | 1316616717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DREXEL UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1427 VINE ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622530 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1427 VINE ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157622530 | ||||||||
| FaxNumber: | 2157622531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2021 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALDOV | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2152557751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.