Basic Information
| Provider Information | |||||||||
| NPI: | 1013263649 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EINSTEIN PRACTICE PLAN, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EINSTEIN PSYCHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500-8735 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154569850 | ||||||||
| FaxNumber: | 2154569442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2012 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR EINSTEIN PRACTICE PLAN INC | ||||||||
| AuthorizedOfficialTelephone: | 2154567000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC2200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1007706230139 | 05 | PA | MEDICAID |