Basic Information
| Provider Information | |||||||||
| NPI: | 1689045437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 HAVERFORD AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191391401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154712761 | ||||||||
| FaxNumber: | 2154726093 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 S 33RD ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191463303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154712761 | ||||||||
| FaxNumber: | 2154726093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | CATER | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2154712761 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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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 | 100728826 | 05 | PA | MEDICAID | 091193 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |