Provider Demographics
NPI:1427589589
Name:PHILEO DISTRICT
Entity Type:Organization
Organization Name:PHILEO DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENT OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:Z
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MSS
Authorized Official - Phone:267-864-7794
Mailing Address - Street 1:6901 OLD YORK RD
Mailing Address - Street 2:C404
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-2234
Mailing Address - Country:US
Mailing Address - Phone:267-864-7794
Mailing Address - Fax:
Practice Address - Street 1:6401 OGONTZ AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126-3406
Practice Address - Country:US
Practice Address - Phone:267-874-6694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1208532600001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028532600001Medicaid