Basic Information
| Provider Information | |||||||||
| NPI: | 1760434468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EINSTEIN PRACTICE PLAN INC | ||||||||
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| OtherOrganizationName: | EINSTEIN PSYCHIATRY ASSOC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 EAST OLNEY AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567000 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK ROAD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567240 | ||||||||
| FaxNumber: | 2154567850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR EINSTEIN PRACTICE PLAN INC | ||||||||
| AuthorizedOfficialTelephone: | 2154567000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1007706230139 | 05 | PA | MEDICAID |