Basic Information
| Provider Information | |||||||||
| NPI: | 1740438944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST TREATMENT CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 N 5TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191234005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154517000 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOLOMONS | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154517000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 104870 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 273261 | 01 | DE | MANAGEG HEALTH NETWORK | OTHER | 159997 | 01 | DE | BLUE CROSS OF DELWARE | OTHER | 1000838 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 311749 | 01 | PA | MAGELLAN - KEYSTONE HEALTH PLAN EAST | OTHER | 1000022246 | 01 | DE | DIAMOND STATE PARTNERS | OTHER | 100773572 | 05 | PA | MEDICAID | 217465 | 01 | DE | UNISON HEALTH PLAN | OTHER | 296503000 | 01 | PA | MAGELLAN HEALTH CHOICES DELAWARE CTY | OTHER | 0004972000 | 01 | PA | MAGELLAN - PERSONAL CHOICE | OTHER | 462315000 | 01 | PA | MAGELLAN HEALTH CHOICES BUCKS/MONTGOMERY CTY'S | OTHER | 100022246 | 05 | DE | MEDICAID | 046410000 | 01 | PA | MAGELLAN - COMMERCIAL | OTHER |