=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104238385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROZER CHESTER MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2014
-----------------------------------------------------
Last Update Date | 05/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 W 9TH ST
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19013-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-520-4595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 W 9TH ST
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19013-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ICM/KID INTENSIVE CASE MANAGER
-----------------------------------------------------
Name | MS. NAKIA SMITH
-----------------------------------------------------
Credential | B.A.
-----------------------------------------------------
Telephone | 856-520-4595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------