MEDICARE: INDEPENDENCE CHARTER SCHOOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)		PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033168026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	105 S 7TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3324
Country	:	US
Telephone Number	:	215-238-8000
Fax Number	:	215-238-1998

Provider Business Practice Location Address
First Line	:	105 S 7TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3324
Country	:	US
Telephone Number	:	215-238-8000
Fax Number	:	215-238-1998

Authorized Official
Title or Position	:	PRINCIPAL/CEO
Name	:	MS. JURATE KROKYS
Credential	:	M.ED.
Telephone Number	:	215-238-8000

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/22/2020

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Directions to “INDEPENDENCE CHARTER SCHOOL ” Practice Location

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