Basic Information
| Provider Information | |||||||||
| NPI: | 1659315380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILADELPHIA VA CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 NORTH 4TH ST. | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159231163 | ||||||||
| FaxNumber: | 2159234032 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 NORTH 4TH ST. | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159231163 | ||||||||
| FaxNumber: | 2159234032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAYERICK | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 2022540339 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.