Basic Information
| Provider Information | |||||||||
| NPI: | 1477053569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEDICATED PENNSYLVANIA HOLDING, LLC | ||||||||
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| OtherOrganizationName: | DEDICATED PENNSYLVANIA MAYFAIR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 N.W/ 167TH STREET | ||||||||
| Address2: | PAYER ENROLLMENT DEPARTMENT | ||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7868704039 | ||||||||
| FaxNumber: | 7868704039 | ||||||||
| Practice Location | |||||||||
| Address1: | 6431 SACKETT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191493118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | 3053635989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2018 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7868704039 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEDICATED PENNSYLVANIA MAYFAIR | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.