Provider Demographics
NPI:1477537827
Name:PHILADELPHIA PROTESTANT HOME
Entity type:Organization
Organization Name:PHILADELPHIA PROTESTANT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-697-8357
Mailing Address - Street 1:6500 TABOR RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-5332
Mailing Address - Country:US
Mailing Address - Phone:215-697-8000
Mailing Address - Fax:215-697-8018
Practice Address - Street 1:6500 TABOR RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-5332
Practice Address - Country:US
Practice Address - Phone:215-697-8000
Practice Address - Fax:215-697-8018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA144500310400000X
PA681002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007494760001Medicaid
PA71-00802OtherEVERCARE
PA0005698000OtherIBC
PA0005698000OtherIBC