Basic Information
| Provider Information | |||||||||
| NPI: | 1598711970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 92 BRICK ROAD OPERATING COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARLTON REHABILITATION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 LENA DR | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175915709 | ||||||||
| FaxNumber: | 7175915710 | ||||||||
| Practice Location | |||||||||
| Address1: | 92 BRICK RD | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080532177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569888778 | ||||||||
| FaxNumber: | 8569886901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/19/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLINGER | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 22252 | NJ | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0001060000 | 01 | NJ | AMERIHEALTH KEYSTONE | OTHER | 313032 | 01 | NJ | HORIZON BLUE CROSS | OTHER | 313032 | 01 | NJ | HORIZON NJ PLUS HMO | OTHER | 313032 | 01 | NJ | HORIZON TRADITIONAL PPO | OTHER | 0001309 | 05 | NJ | MEDICAID | 001060 | 01 | NJ | AMERIHEALTH | OTHER | 313032 | 01 | NJ | FEDERAL BLUE CROSS | OTHER | 7828294 | 01 | NJ | AETNA GOLDEN MEDICARE | OTHER | 313032 | 01 | NJ | HORIZON MERCY | OTHER | 313032 | 01 | NJ | HORIZON NATIONAL | OTHER | 313032 | 01 | NJ | HORIZON CASUALTY | OTHER | AETNA BLUE BELL | 01 | NJ | 2784259 | OTHER |