Basic Information
| Provider Information | |||||||||
| NPI: | 1487082608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILADELPHIA FIGHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 LOCUST ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159854448 | ||||||||
| FaxNumber: | 2157321145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 LOCUST ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157901788 | ||||||||
| FaxNumber: | 2157325490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2013 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | VIRELLA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9178423011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 100747222 | 05 | PA | MEDICAID |