Basic Information
| Provider Information | |||||||||
| NPI: | 1942703137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEDICATED PENNSYLVANIA HOLDING, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DEDICATED PENNSYLVANIA WEST PHILADELPHIA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1395 N.W/ 167TH STREET | ||||||||
| Address2: | PAYER ENROLLMENT DEPARTMENT | ||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7868704039 | ||||||||
| FaxNumber: | 7868704039 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 N 52ND ST STE S-3 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191314736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SVCS | ||||||||
| AuthorizedOfficialTelephone: | 7868704039 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEDICATED PENNSYLVANIA HOLDING, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.