Basic Information
Provider Information | |||||||||
NPI: | 1720173776 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDRENS HEALTH CARE ASSOCIATES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHCA ALLERGY & IMMUNOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E PENN SQ FL 9 | ||||||||
Address2: | CHILDREN'S HEALTHCARE ASSOCIATES | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191073323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2674259233 | ||||||||
FaxNumber: | 2674259299 | ||||||||
Practice Location | |||||||||
Address1: | 3401 CIVIC CENTER BLVD | ||||||||
Address2: | CHILDREN'S HOSPITAL OF PHILADELPHIA | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155901000 | ||||||||
FaxNumber: | 2674259299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 10/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANTA | ||||||||
AuthorizedOfficialFirstName: | MIXZA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2674259233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
ID | Type | State | Issuer | Description | 01156798 | 05 | NY |   | MEDICAID | 0000188502 | 05 | DE |   | MEDICAID | 3316602 | 05 | NJ |   | MEDICAID | 0006558520003 | 05 | PA |   | MEDICAID |