Provider Demographics
NPI:1205810587
Name:IMMACULATE MARY HOME
Entity type:Organization
Organization Name:IMMACULATE MARY HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CZEKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-0900
Mailing Address - Street 1:2990 HOLME AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-1830
Mailing Address - Country:US
Mailing Address - Phone:215-335-2100
Mailing Address - Fax:215-331-9105
Practice Address - Street 1:2990 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-1830
Practice Address - Country:US
Practice Address - Phone:215-335-2100
Practice Address - Fax:215-331-9105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH CARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-01
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA090902314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007570930002Medicaid
PA0556883OtherAETNA
PA395338OtherIBC KEYSTONE
PA0007570930002Medicaid