Provider Demographics
NPI:1114975869
Name:TPS II OF PA, LLC
Entity Type:Organization
Organization Name:TPS II OF PA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-762-4312
Mailing Address - Street 1:245 N. BROAD ST
Mailing Address - Street 2:MS 310
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 N BROAD ST
Practice Address - Street 2:MS 310
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19107-1518
Practice Address - Country:US
Practice Address - Phone:215-762-4312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012189070001Medicaid
PA1012189070001Medicaid