1215548615 NPI number — ELWYN OF PENNSYLVANIA AND DELAWARE

Table of content: (NPI 1215548615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215548615 NPI number — ELWYN OF PENNSYLVANIA AND DELAWARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELWYN OF PENNSYLVANIA AND DELAWARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN 2
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215548615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 ELWYN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19063-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-891-7007
Provider Business Mailing Address Fax Number:
610-891-2666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 ELWYN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19063-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-891-7007
Provider Business Practice Location Address Fax Number:
610-891-2666
Provider Enumeration Date:
08/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BUSCH
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PAYER CONTRACT SPECIALIST
Authorized Official Telephone Number:
445-206-3028

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1000021240700 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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