Basic Information
Provider Information | |||||||||
NPI: | 1801963343 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEFFERSON HEALTH - NORTHEAST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARIA HEALTH TORRESDALE CAMPUS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 781001 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191781001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2154816873 | ||||||||
FaxNumber: | 2154813985 | ||||||||
Practice Location | |||||||||
Address1: | 10800 KNIGHTS RD | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191144200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2156124000 | ||||||||
FaxNumber: | 2157103731 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GALUP | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2156125038 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 061801 | PA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 120373 | 01 | PA | AETNA HMO | OTHER | 0001010000 | 01 | PA | PERSONAL CHOICE | OTHER | 16465 | 01 | PA | HEALTH PARTNERS | OTHER | 1007705250011 | 05 | PA |   | MEDICAID | 4193300 | 01 | NJ | MEDICAID OF NEW JERSEY | OTHER | 0001010000 | 01 | PA | KEYSTONE IBC | OTHER | 390115B | 01 | PA | CCN | OTHER | 0073204903 | 01 | PA | AMERICHOICE | OTHER | 60086 | 01 | PA | KEYSTONE MERCY | OTHER | 6490865 | 01 | PA | AETNA PPO | OTHER |