Basic Information
| Provider Information | |||||||||
| NPI: | 1083709042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HEALTH CARE ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CHCA METABOLISM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N 20TH ST STE 301 | ||||||||
| Address2: | CHCA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191031454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155672422 | ||||||||
| FaxNumber: | 2155610959 | ||||||||
| Practice Location | |||||||||
| Address1: | 34TH & CIVIC CENTER BLVD | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | 2159778864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | SANTA | ||||||||
| AuthorizedOfficialFirstName: | MIXZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2155672422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0000188502 | 05 | DE | MEDICAID | 3316602 | 05 | NJ | MEDICAID | 0006558520003 | 05 | PA | MEDICAID | 01156798 | 05 | NY | MEDICAID |