Basic Information
| Provider Information | |||||||||
| NPI: | 1265500185 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENN FOUNDATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ASSERTIVE COMMUNITY TREATMENT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 807 LAWN AVENUE | ||||||||
| Address2: | PO BOX 32 | ||||||||
| City: | SELLERSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152576551 | ||||||||
| FaxNumber: | 2152579347 | ||||||||
| Practice Location | |||||||||
| Address1: | SUNNYBROOK VILLAGE | ||||||||
| Address2: | 500 CREEKSIDE DRIVE | ||||||||
| City: | SUITE 507 | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108196000 | ||||||||
| FaxNumber: | 6108196004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MUGRAUER | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2152576551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 129323 | 01 | PA | HEALTH CHOICES | OTHER | PE113171 | 05 | PA | MEDICAID |