Basic Information
| Provider Information | |||||||||
| NPI: | 1356893085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HEALTH MANAGMENT CORPORATION (PHMC) | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PHMC PATHWAYS TO RECOVERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 MARKET STREET | ||||||||
| Address2: | LM500, LOWER MEZZANINE, WEST TOWER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191025000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159852500 | ||||||||
| FaxNumber: | 2159852550 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 E ALLEGHENY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191344427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157312402 | ||||||||
| FaxNumber: | 2675924123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2016 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WUSSOW | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | MILTON | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF FIN & REG AFFIRS FOR BHS | ||||||||
| AuthorizedOfficialTelephone: | 2159852575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 807439 | PA | Y | Agencies | Community/Behavioral Health |
No ID Information.