Provider Demographics
NPI:1477053569
Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Entity Type:Organization
Organization Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Other - Org Name:DEDICATED PENNSYLVANIA MAYFAIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLIENT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-870-4039
Mailing Address - Street 1:1395 N.W/ 167TH STREET
Mailing Address - Street 2:PAYER ENROLLMENT DEPARTMENT
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169
Mailing Address - Country:US
Mailing Address - Phone:786-870-4039
Mailing Address - Fax:786-870-4039
Practice Address - Street 1:6431 SACKETT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-3118
Practice Address - Country:US
Practice Address - Phone:305-628-6117
Practice Address - Fax:305-363-5989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEDICATED PENNSYLVANIA MAYFAIR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-15
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty