=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396079695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON HEADACHE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2009
-----------------------------------------------------
Last Update Date | 09/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S 11TH ST SUITE 8130 GIBBON BUILDING
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-2727
-----------------------------------------------------
Fax | 215-955-6682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 S 11TH ST SUITE 8130 GIBBON BUILDING
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-2727
-----------------------------------------------------
Fax | 215-955-6682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MS. PATRICE S GUILD
-----------------------------------------------------
Credential | DIRECTOR, OPERATIONS
-----------------------------------------------------
Telephone | 215-955-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 438132
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------