Provider Demographics
NPI:1679528558
Name:WEST PHILADELPHIA MEDICAL & REHABILITATION, P.C.
Entity Type:Organization
Organization Name:WEST PHILADELPHIA MEDICAL & REHABILITATION, P.C.
Other - Org Name:NORTH PHILADELPHIA MEDICAL & REHABITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RICCA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:215-947-5800
Mailing Address - Street 1:5942 HAVERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-4333
Mailing Address - Country:US
Mailing Address - Phone:215-474-9982
Mailing Address - Fax:
Practice Address - Street 1:2600 PHILMONT AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-5306
Practice Address - Country:US
Practice Address - Phone:215-947-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006957L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA909555Medicare ID - Type Unspecified