Basic Information
| Provider Information | |||||||||
| NPI: | 1972695740 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOP CLINICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHOP BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3440 MARKET ST | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155907532 | ||||||||
| FaxNumber: | 2155904251 | ||||||||
| Practice Location | |||||||||
| Address1: | 4009 BLACK HORSE PIKE | ||||||||
| Address2: | |||||||||
| City: | MAYS LANDING | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083303133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155907555 | ||||||||
| FaxNumber: | 2155907387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | BLEACHER | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REV CYCLE & REIM STRATEGY | ||||||||
| AuthorizedOfficialTelephone: | 2674266179 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHOP CLINICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 2084P0804X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.