Basic Information
| Provider Information | |||||||||
| NPI: | 1407909088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALL-MERCER CMH-MRC OF PENNSYLVANIA HOSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191063520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 6097707792 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MARKET ST | ||||||||
| Address2: | UM600 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191022100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157964640 | ||||||||
| FaxNumber: | 6097707792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2157964640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENNSYLVANIA HOSPITAL OF THE UNIV OF PA HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1000049150013 | 05 | PA | MEDICAID |