Basic Information
| Provider Information | |||||||||
| NPI: | 1881738565 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT AGNES CONTINUING CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191452304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153394223 | ||||||||
| FaxNumber: | 2153390482 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191452304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153394223 | ||||||||
| FaxNumber: | 2153390482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | SCHMOTZER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2153394533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | Y | Agencies | PACE Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 1003050510004 | 05 | PA | MEDICAID |