Basic Information
| Provider Information | |||||||||
| NPI: | 1609825801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTENSIVIST GROUP OF PENNSYLVANIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 4931 | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601224931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006552656 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SOUTH 54TH STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157489000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | COWEN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8006552656 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1637821 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 30019158 | 01 | PA | KEYSTONE MERCY | OTHER | DC3119 | 01 | PA | RAILROAD MEDICARE | OTHER | 2315456000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 1010047220001 | 05 | PA | MEDICAID | 34928 | 01 | PA | HEALTH PARTNERS | OTHER |