Provider Demographics
NPI:1417007204
Name:CHILRENS HOSPITAL OF PHILADELPHIA
Entity Type:Organization
Organization Name:CHILRENS HOSPITAL OF PHILADELPHIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIERDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-426-5722
Mailing Address - Street 1:34TH & CIVIC CENTER BLVD
Mailing Address - Street 2:PARC BUSINESS SERVICES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:267-426-5722
Mailing Address - Fax:267-426-6325
Practice Address - Street 1:34TH & CIVIC CENTER BLVD
Practice Address - Street 2:PARC BUSINESS SERVICES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:267-426-5722
Practice Address - Fax:267-426-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007709910078Medicaid