Provider Demographics
NPI:1053466086
Name:PHILADELPHIA HEALTH MANAGEMENT CORP
Entity Type:Organization
Organization Name:PHILADELPHIA HEALTH MANAGEMENT CORP
Other - Org Name:WEST HAVEN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-985-2501
Mailing Address - Street 1:260 S BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102
Mailing Address - Country:US
Mailing Address - Phone:215-985-2500
Mailing Address - Fax:215-731-2049
Practice Address - Street 1:111 N 49TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-2718
Practice Address - Country:US
Practice Address - Phone:215-662-8881
Practice Address - Fax:215-662-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA122660261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000016640041Medicare ID - Type Unspecified