Basic Information
| Provider Information | |||||||||
| NPI: | 1750395653 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HEALTH MANAGEMENT CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHILADELPHIA HEALTH MANAGEMENT CORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 S BROAD ST FL 18 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191025000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159852514 | ||||||||
| FaxNumber: | 2677652325 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 ADAMS AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152796666 | ||||||||
| FaxNumber: | 2152799674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KILLIAN | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2159852514 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | G001140710 | 01 | PA | AMERICHOICE OF PA | OTHER | 2287757001 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 30010912 | 01 | PA | KEYSTONE MERCY | OTHER | 33926 | 01 | PA | HEALTH PARTNERS OF PA | OTHER | 001599865 | 01 | PA | PA HIGHMARK BLUE SHIELD | OTHER | 85942 | 01 | PA | AETNA | OTHER |