Healthcare Provider Details

I. General information

NPI: 1588786487
Provider Name (Legal Business Name): WEST PHILADELPHIA COMMUNITY MH CONSORTIUM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 VINE ST
PHILADELPHIA PA
19103-1117
US

IV. Provider business mailing address

3801 MARKET ST SUITE 201
PHILADELPHIA PA
19104-3153
US

V. Phone/Fax

Practice location:
  • Phone: 215-596-8100
  • Fax: 215-382-4405
Mailing address:
  • Phone: 215-596-8100
  • Fax: 215-382-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number1007155230075
License Number StatePA

VIII. Authorized Official

Name: MR. JOHN F. WHITE JR.
Title or Position: PRESIDENT CEO
Credential:
Phone: 215-596-8100