Provider Demographics
NPI:1730321688
Name:PHMC IMMUNIZATION PROGRAM
Entity Type:Organization
Organization Name:PHMC IMMUNIZATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TINDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-985-2523
Mailing Address - Street 1:260 S BROAD ST
Mailing Address - Street 2:18TH FL ATTN: B TINDALL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-5021
Mailing Address - Country:US
Mailing Address - Phone:215-985-2523
Mailing Address - Fax:215-731-2049
Practice Address - Street 1:1430 CHERRY ST
Practice Address - Street 2:
Practice Address - City:PHILDELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1526
Practice Address - Country:US
Practice Address - Phone:215-686-7150
Practice Address - Fax:215-569-1532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service