Provider Demographics
NPI:1295192193
Name:THE CHILDREN'S HOSPITAL OF PHILADELPHIA
Entity Type:Organization
Organization Name:THE CHILDREN'S HOSPITAL OF PHILADELPHIA
Other - Org Name:CHOP CARE NETWORK MT. LAUREL
Other - Org Type:Other Name
Authorized Official - Title/Position:CPNP-PC
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CANAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:856-979-2088
Mailing Address - Street 1:3201 MARNE HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-9716
Mailing Address - Country:US
Mailing Address - Phone:856-235-2147
Mailing Address - Fax:
Practice Address - Street 1:3201 MARNE HWY
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-9716
Practice Address - Country:US
Practice Address - Phone:856-235-2147
Practice Address - Fax:856-235-6905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00616800261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care