Basic Information
| Provider Information | |||||||||
| NPI: | 1992914311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESOURCES FOR HUMAN DEVELOPMENT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MONTGOMERY COUNTY METHADONE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | SUITE 126 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159510300 | ||||||||
| FaxNumber: | 2158497360 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 DEKALB ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194014906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102723710 | ||||||||
| FaxNumber: | 6102700760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FISHMAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2159510300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 465074 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 1000017080227 | 05 | PA | MEDICAID |