Provider Demographics
NPI:1902403694
Name:CHILDREN'S HOSPITAL OF PHILADELPHIA
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF PHILADELPHIA
Other - Org Name:KENNETT SQUARE HEALTHY WEIGHT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRS
Authorized Official - Prefix:
Authorized Official - First Name:GALENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-590-2897
Mailing Address - Street 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 E BALTIMORE PIKE. SUITE A
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-1929
Practice Address - Country:US
Practice Address - Phone:610-444-0113
Practice Address - Fax:610-444-0744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL OF PHILADELPHIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-06
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007709910121Medicaid