Basic Information
| Provider Information | |||||||||
| NPI: | 1073819967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELAWARE VALLEY COMMUNITY HEALTH, INC. | ||||||||
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| OtherOrganizationName: | FAIRMOUNT PRIMARY CARE CENTER AT ST. JOSEPH'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191302908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155994851 | ||||||||
| FaxNumber: | 2152324093 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W GIRARD AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191301615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158278010 | ||||||||
| FaxNumber: | 2157652191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | DEITCH | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2152359600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELAWARE VALLEY COMMUNITY HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.