Basic Information
| Provider Information | |||||||||
| NPI: | 1902267230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METHODIST ASSOCIATES IN HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JEFFERSON COMMUNITY PHYSICIANS-NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 828937 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155031240 | ||||||||
| FaxNumber: | 2159521247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159529936 | ||||||||
| FaxNumber: | 2159521247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | RISTOS | ||||||||
| AuthorizedOfficialFirstName: | HRISTAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 2159559298 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.