Provider Demographics
NPI:1952481616
Name:PENN PSYCHIATRIC CENTER INC
Entity Type:Organization
Organization Name:PENN PSYCHIATRIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-917-2200
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:GWYNEDD VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19437-0187
Mailing Address - Country:US
Mailing Address - Phone:610-917-2200
Mailing Address - Fax:610-917-2360
Practice Address - Street 1:601 GAY ST
Practice Address - Street 2:SUITE6
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3852
Practice Address - Country:US
Practice Address - Phone:610-917-2200
Practice Address - Fax:610-917-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA039341L251S00000X
PA117910261Q00000X, 261QM0801X, 261QM0850X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10753391Medicaid
PA734714Medicare ID - Type Unspecified
PA10753391Medicaid