Healthcare Provider Details

I. General information

NPI: 1063466068
Provider Name (Legal Business Name): GREATER PHILADELPHIA HEALTH ACTION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1999 W HUNTING PARK AVE
PHILADELPHIA PA
19140-2828
US

IV. Provider business mailing address

1401 S 31ST ST 2ND FLOOR
PHILADELPHIA PA
19146-3506
US

V. Phone/Fax

Practice location:
  • Phone: 215-228-9300
  • Fax: 215-228-9913
Mailing address:
  • Phone: 215-925-2400
  • Fax: 215-925-9162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: D TINA SMITH
Title or Position: PROVIDER ENROLLMENT SPEC.
Credential:
Phone: 215-925-2400