Provider Demographics
NPI:1164938726
Name:CONVENIENT CARE COLLABORATION LLC
Entity Type:Organization
Organization Name:CONVENIENT CARE COLLABORATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNP/ PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SIEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARROW
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:267-975-6765
Mailing Address - Street 1:5250 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-3622
Mailing Address - Country:US
Mailing Address - Phone:267-975-6765
Mailing Address - Fax:267-200-0924
Practice Address - Street 1:5250 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-3622
Practice Address - Country:US
Practice Address - Phone:267-975-6765
Practice Address - Fax:267-200-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1265634042Medicaid