Basic Information
| Provider Information | |||||||||
| NPI: | 1538619333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELAWARE VALLEY COMMUNITY HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAIRMOUNT PRIMARY CARE CENTER AT GIRARD MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412-22 FAIRMOUNT AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191302908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156845344 | ||||||||
| FaxNumber: | 2152324093 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 W. THOMPSON STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191224212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158278010 | ||||||||
| FaxNumber: | 2152321037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2016 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCNEAL | ||||||||
| AuthorizedOfficialFirstName: | ALVAN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 2156845344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1007729960028 | 05 | PA | MEDICAID |