Healthcare Provider Details

I. General information

NPI: 1790130672
Provider Name (Legal Business Name): PROSPECT DCMH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N LANSDOWNE AVE
DREXEL HILL PA
19026-1114
US

IV. Provider business mailing address

501 N LANSDOWNE AVE
DREXEL HILL PA
19026-1114
US

V. Phone/Fax

Practice location:
  • Phone: 610-284-8100
  • Fax: 610-447-6620
Mailing address:
  • Phone: 610-284-8100
  • Fax: 610-447-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ROBERT JON ELDERS
Title or Position: SECRETARY
Credential:
Phone: 714-788-1249