Basic Information
| Provider Information | |||||||||
| NPI: | 1700438660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MALVERN CONSTITUTION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 GERMANTOWN PIKE STE G5 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194622487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413390 | ||||||||
| FaxNumber: | 6109413391 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191452328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | OWEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6109413390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
No ID Information.