Provider Demographics
NPI:1417977257
Name:DEVELOPMENTAL DISABILITIES HEALTH SERVICES PA
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES HEALTH SERVICES PA
Other - Org Name:DEVELOPMENTAL DISABILITES HEALTH ALLIANCE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KASTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, M S
Authorized Official - Phone:973-338-4200
Mailing Address - Street 1:1285 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3045
Mailing Address - Country:US
Mailing Address - Phone:973-338-4200
Mailing Address - Fax:973-338-4440
Practice Address - Street 1:1285 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3045
Practice Address - Country:US
Practice Address - Phone:973-338-4200
Practice Address - Fax:973-338-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ161730Medicaid
NJ8448701Medicaid
NJ161730Medicaid
NJ163665Medicare UPIN
NJ163665Medicare UPIN