Provider Demographics
NPI:1841707965
Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Entity type:Organization
Organization Name:DEDICATED PENNSYLVANIA HOLDING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-628-6117
Mailing Address - Street 1:1395 N.W/ 167TH STREET
Mailing Address - Street 2:PAYER ENROLLMENT DEPARTMENT
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:786-870-4039
Practice Address - Street 1:5675 N FRONT ST STE 141
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2719
Practice Address - Country:US
Practice Address - Phone:305-628-6117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEDICATED PENNSYLVANIA HOLDING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-10
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty