Basic Information
| Provider Information | |||||||||
| NPI: | 1801872320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENNSYLVANIA LTC INC | ||||||||
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| OtherOrganizationName: | EDGEHILL NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6103474099 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 EDGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | GLENSIDE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190383004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158861043 | ||||||||
| FaxNumber: | 2158862719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109254321 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 052702 | PA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 052702 | PA | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 052702 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1007653650003 | 05 | PA | MEDICAID |