Basic Information
| Provider Information | |||||||||
| NPI: | 1770925992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST TREATMENT CENTERS, INC | ||||||||
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| 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: | 1709 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191461913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155468060 | ||||||||
| FaxNumber: | 2159256897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2013 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | STINSON | ||||||||
| AuthorizedOfficialFirstName: | ANNEMARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2154517015 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253J00000X | 140040 | PA | Y | Agencies | Foster Care Agency |
ID Information
| ID | Type | State | Issuer | Description | 0004972000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 100773572 | 05 | PA | MEDICAID | 311749 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER |