MEDICARE: KIPP PHILADELPHIA 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

General Provider Information

NPI Number	:	1740438100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIPP PHILADELPHIA CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	2709 N BROAD ST
Second Line	:	4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-2722
Country	:	US
Telephone Number	:	215-852-1532
Fax Number	:

Provider Business Practice Location Address
First Line	:	2709 N BROAD ST
Second Line	:	4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-2722
Country	:	US
Telephone Number	:	215-852-1532
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARC P MANNELLA
Credential	:	MA
Telephone Number	:	215-227-1728

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	08/28/2008

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