Provider Demographics
NPI:1538667704
Name:PREMIER URGENT CARE AT KENNETT SQUARE, LLC
Entity Type:Organization
Organization Name:PREMIER URGENT CARE AT KENNETT SQUARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-552-2818
Mailing Address - Street 1:10050 ROOSEVELT BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3965
Mailing Address - Country:US
Mailing Address - Phone:215-552-2818
Mailing Address - Fax:484-713-5255
Practice Address - Street 1:10050 ROOSEVELT BLVD STE 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3965
Practice Address - Country:US
Practice Address - Phone:215-552-2818
Practice Address - Fax:484-713-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027657760001Medicaid