Basic Information
| Provider Information | |||||||||
| NPI: | 1114959582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENET HEALTHSYSTEM ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. CHRISTOPHERS HOSPITAL FOR CHILDREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 828125 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191828125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152553152 | ||||||||
| FaxNumber: | 2154275555 | ||||||||
| Practice Location | |||||||||
| Address1: | ERIE AVENUE @ FRONT ST. | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191341095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | ARMIN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF GOVT PROGRAMS, TENET | ||||||||
| AuthorizedOfficialTelephone: | 8184362267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| 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 | 282NC2000X | 195601 | PA | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 019369900 | 05 | DC | MEDICAID | 1007296720002 | 05 | PA | MEDICAID | 75-2522262 | 01 | BETTER HEALTH PLAN | OTHER | 003114767 | 05 | CT | MEDICAID | 64872238 | 05 | CO | MEDICAID | HSP231515 | 05 | CA | MEDICAID | STC00301N | 05 | AL | MEDICAID | 100470930 | 05 | IN | MEDICAID | 1007296720007 | 05 | PA | MEDICAID | 2311 | 01 | INDEPENDENCE BLUE CROSS | OTHER | 00017 | 01 | HEALTH PARTNERS | OTHER | 4660903 | 05 | MI | MEDICAID | 1007296720010 | 05 | PA | MEDICAID | 378638200 | 05 | MN | MEDICAID | 4660897 | 05 | MI | MEDICAID | 7009461 | 05 | MA | MEDICAID | 000757589Y | 05 | GA | MEDICAID | 00757589X | 05 | GA | MEDICAID | 393307 | 01 | HORIZON NJ-BCBS HEALTH | OTHER |