Basic Information
| Provider Information | |||||||||
| NPI: | 1669715660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PA RTE 120 INPATIENT SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37928 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191010528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RENOVO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177641618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709231000 | ||||||||
| FaxNumber: | 5709231189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8004447009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.