Provider Demographics
NPI:1407975998
Name:WEST PHILADELPHIA COMMUNITY MH CONSORTIUM, INC.
Entity Type:Organization
Organization Name:WEST PHILADELPHIA COMMUNITY MH CONSORTIUM, INC.
Other - Org Name:THE CONSORTIUM, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-596-8100
Mailing Address - Street 1:3751 ISLAND AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-3237
Mailing Address - Country:US
Mailing Address - Phone:215-596-8100
Mailing Address - Fax:215-382-0511
Practice Address - Street 1:137 S 58TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3134
Practice Address - Country:US
Practice Address - Phone:215-596-8100
Practice Address - Fax:215-382-0511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1007155230014251B00000X
PA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007155230014Medicaid
PA1007155230107Medicaid