Basic Information
| Provider Information | |||||||||
| NPI: | 1023048717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENET HEALTHSYSTEM GRADUATE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRADUATE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 828120 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152553152 | ||||||||
| FaxNumber: | 2158932302 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191468400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158932000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARMIN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF GOVT PROGRAMS, TENET | ||||||||
| AuthorizedOfficialTelephone: | 8184362267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282N00000X | 073001 | PA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000418 | 01 | HUMANA | OTHER | 15624 | 01 | HEALTH PARTNERS | OTHER | X000483602 | 01 | AMERICHOICE NEW JERSEY | OTHER | 01999637 | 05 | NY | MEDICAID | 1001275950006 | 05 | PA | MEDICAID | GRA0285N | 05 | IN | MEDICAID | 1000017120 | 05 | DE | MEDICAID | 11038A | 05 | SC | MEDICAID | 0390285 | 05 | VT | MEDICAID | 1001275950004 | 05 | PA | MEDICAID | 37137100 | 05 | DC | MEDICAID | 11233B | 05 | SC | MEDICAID | 2309 | 01 | INDEPENDENCE BLUE CROSS | OTHER | 3900285 | 05 | NC | MEDICAID | 9517502 00 | 05 | MD | MEDICAID | 000841822 | 01 | AETNA US HEALTHCARE | OTHER | 010055148 | 05 | VA | MEDICAID | 60009 | 01 | KEYSTONE MERCY HEALTH PLA | OTHER | 802-9709 | 05 | NJ | MEDICAID |