Provider Demographics
NPI:1780746917
Name:PHILADELPHIA MENTAL HEALTH CLINIC
Entity type:Organization
Organization Name:PHILADELPHIA MENTAL HEALTH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-735-9379
Mailing Address - Street 1:1235 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5945
Mailing Address - Country:US
Mailing Address - Phone:215-598-0223
Mailing Address - Fax:215-598-9020
Practice Address - Street 1:1235 PINE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5945
Practice Address - Country:US
Practice Address - Phone:215-598-0223
Practice Address - Fax:215-598-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA123880261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA265050000OtherMAGELLAN BEHAVIORAL HEALT
PA000138598OtherBCBS
PA1007279540006Medicaid
PA0056455000OtherBC
PA000138598OtherBCBS