Provider Demographics
NPI:1114063633
Name:PROGRESSIVE HEALTH OF PENNSYLVANIA INC.
Entity Type:Organization
Organization Name:PROGRESSIVE HEALTH OF PENNSYLVANIA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-296-5156
Mailing Address - Street 1:110 EAST HARFORD STREET
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-1002
Mailing Address - Country:US
Mailing Address - Phone:570-296-5156
Mailing Address - Fax:570-296-2592
Practice Address - Street 1:110 E HARFORD ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-1002
Practice Address - Country:US
Practice Address - Phone:570-296-5156
Practice Address - Fax:570-296-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1006808200002Medicaid
PA1006808200002Medicaid
PA396704Medicare ID - Type Unspecified