Basic Information
| Provider Information | |||||||||
| NPI: | 1881854578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELAWARE VALLEY COMMUNITY HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DVCH OB GYN SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412-22 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152359600 | ||||||||
| FaxNumber: | 2152324093 | ||||||||
| Practice Location | |||||||||
| Address1: | 401-55 W ALLEGHENY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152912500 | ||||||||
| FaxNumber: | 2152912587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEITCH | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2156845344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DELAWARE VALLEY COMMUNITY HEALTH INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1007729960020 | 05 | PA | MEDICAID |