Provider Demographics
NPI:1730306291
Name:THE WEDGE MEDICAL CENTER, P.C.
Entity Type:Organization
Organization Name:THE WEDGE MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAKISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-276-3922
Mailing Address - Street 1:2009 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2217
Mailing Address - Country:US
Mailing Address - Phone:215-271-2200
Mailing Address - Fax:215-271-2333
Practice Address - Street 1:2009 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2217
Practice Address - Country:US
Practice Address - Phone:215-271-2200
Practice Address - Fax:215-271-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA807376101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007281920007Medicaid
PA1007281920010Medicaid