Provider Demographics
NPI:1396799722
Name:1223 SOUTH 15TH STREET CORPORATION
Entity type:Organization
Organization Name:1223 SOUTH 15TH STREET CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:A
Authorized Official - Last Name:COCCO
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:215-334-3816
Mailing Address - Street 1:2745 W PASSYUNK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4012
Mailing Address - Country:US
Mailing Address - Phone:215-334-3816
Mailing Address - Fax:215-334-1998
Practice Address - Street 1:2745 W PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4012
Practice Address - Country:US
Practice Address - Phone:215-334-3816
Practice Address - Fax:215-334-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000003764332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39000573532Medicaid
PA39000573532Medicaid