Provider Demographics
NPI:1336792316
Name:WEDGE MEDICAL CENTER
Entity Type:Organization
Organization Name:WEDGE MEDICAL CENTER
Other - Org Name:WEDGE MEDICAL CENTER, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAKISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-276-3922
Mailing Address - Street 1:6711 OLD YORK RD OFC
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-2841
Mailing Address - Country:US
Mailing Address - Phone:215-276-3922
Mailing Address - Fax:215-276-1249
Practice Address - Street 1:3600 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4226
Practice Address - Country:US
Practice Address - Phone:215-223-3600
Practice Address - Fax:215-223-2100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEDGE MEDICAL CENTER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-19
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001680493Medicaid