Basic Information
| Provider Information | |||||||||
| NPI: | 1770550089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEMPLE PEDIATRIC EMERGENCY MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820890 | ||||||||
| Address2: | TEMPLE PEDIATRIC EMERGENCY MEDICAL ASSOCIATES | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006662455 | ||||||||
| FaxNumber: | 6106176280 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 N BROAD ST | ||||||||
| Address2: | TEMPLE UNIVERSITY CHILDRENS MEDICAL CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157076606 | ||||||||
| FaxNumber: | 2157076629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLOOD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | GREGORY | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2157076606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007780130283 | 05 | PA | MEDICAID | 278955 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0647502000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER |