Provider Demographics
NPI:1760644744
Name:PHILADELPHIA MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:PHILADELPHIA MENTAL HEALTH CLINIC
Other - Org Name:PHILADELPHIA MENTAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR BILLING/PC SYSTEMS
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-735-5674
Mailing Address - Street 1:1235 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5945
Mailing Address - Country:US
Mailing Address - Phone:215-735-9379
Mailing Address - Fax:215-735-8806
Practice Address - Street 1:1235 PINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5945
Practice Address - Country:US
Practice Address - Phone:215-735-9379
Practice Address - Fax:215-735-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA123880261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007279540005Medicaid
PA265050000OtherMAGELLAN
PA000138598OtherBC
PA1007279540005Medicaid