Basic Information
| Provider Information | |||||||||
| NPI: | 1518056944 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WASHINGTON PHYSICIAN SERVICES ORGANIZATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON HEALTH SYSTEM PEDS AND ADOLESCENT CARE - WASHINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WELLNESS WAY BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153019706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242506001 | ||||||||
| FaxNumber: | 7242506004 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WELLNESS WAY | ||||||||
| Address2: | BLDG 2 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153019706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242506001 | ||||||||
| FaxNumber: | 7242506004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCANLON | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7242291756 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WASHINGTON HEALTH CARE SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0015918490027 | 05 | PA | MEDICAID |