Provider Demographics
NPI:1659541472
Name:PHILADELPHIA HEALTH MANAGEMENT CORPORATION (PHMC) / GIRLSPACE
Entity Type:Organization
Organization Name:PHILADELPHIA HEALTH MANAGEMENT CORPORATION (PHMC) / GIRLSPACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-731-2042
Mailing Address - Street 1:111 N 49TH ST # 222
Mailing Address - Street 2:2ND FL, SOUTH BLDG.
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N 49TH ST # 222
Practice Address - Street 2:2ND FL, SOUTH BLDG.
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19139-2718
Practice Address - Country:US
Practice Address - Phone:215-731-2042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000016640048Medicaid