Basic Information
| Provider Information | |||||||||
| NPI: | 1851745566 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENSINGTON HOSPITAL OUTPATIENT TREATMENT PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 N FRONT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191221705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154268100 | ||||||||
| FaxNumber: | 2159652344 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 N FRONT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191221705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154268100 | ||||||||
| FaxNumber: | 2159652344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | LALLI | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2154268100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENSINGTON HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | MSN, RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 400451 | 01 | PA | MEDICARE PTAN | OTHER |