Provider Demographics
NPI: | 1508936071 |
---|---|
Name: | CHESTNUT HILL CLINIC COMPANY, LLC |
Entity Type: | Organization |
Organization Name: | CHESTNUT HILL CLINIC COMPANY, LLC |
Other - Org Name: | FAMILY MEDICINE WYNCOTE TOWER HEALTH MEDICAL GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SR VP FINANCIAL OPERATIONS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROBERT |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | EHINGER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 484-628-4681 |
Mailing Address - Street 1: | PO BOX 13579 |
Mailing Address - Street 2: | |
Mailing Address - City: | READING |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19612-3579 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 8835 GERMANTOWN AVE |
Practice Address - Street 2: | |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19118-2718 |
Practice Address - Country: | US |
Practice Address - Phone: | 215-248-8200 |
Practice Address - Fax: | 215-248-1022 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-11-09 |
Last Update Date: | 2021-11-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 101823623 | Medicaid | |
PA | 101823623 | Medicaid |