Provider Demographics
NPI:1851390561
Name:CORECARE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:CORECARE BEHAVIORAL HEALTH
Other - Org Name:KIRKBRIDE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIOTTAVIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-471-2853
Mailing Address - Street 1:111 N 49TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-2718
Mailing Address - Country:US
Mailing Address - Phone:215-471-2488
Mailing Address - Fax:
Practice Address - Street 1:111 N 49TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-2718
Practice Address - Country:US
Practice Address - Phone:215-471-2488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA197910273R00000X
PA807208273Y00000X, 276400000X
283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No273Y00000XHospital UnitsRehabilitation Unit
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007737600004Medicaid
PA1007737600004Medicaid