Basic Information
| Provider Information | |||||||||
| NPI: | 1477701670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST TREATMENT CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOLOMONS | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154517000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 807408 | PA | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | 807408 | PA | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | 807408 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100773572 | 05 | PA | MEDICAID |