Basic Information
| Provider Information | |||||||||
| NPI: | 1801981857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HEALTH CARE ASSOCIATES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHCA GASTROENTEROLOGY & NUTRITION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD STE M975 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259408 | ||||||||
| FaxNumber: | 2674431341 | ||||||||
| 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: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | FLOWERS | ||||||||
| AuthorizedOfficialFirstName: | CHERISH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2674259408 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 3316602 | 05 | NJ | MEDICAID | 0006558520003 | 05 | PA | MEDICAID | 01156798 | 05 | NY | MEDICAID | 0000188502 | 05 | DE | MEDICAID |