Basic Information
Provider Information | |||||||||
NPI: | 1922273564 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GAUDENZIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GAUDENZIA WINNER PROGRAM | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | NORRISTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 194014716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102399600 | ||||||||
FaxNumber: | 6102757025 | ||||||||
Practice Location | |||||||||
Address1: | 1834 W TIOGA ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191404939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152287595 | ||||||||
FaxNumber: | 2159657779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2008 | ||||||||
LastUpdateDate: | 03/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SR. CONTRACTING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4843383731 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 807404 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 1002285890071 | 05 | PA |   | MEDICAID |