=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447091194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 E ERIE AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-427-8783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6165 ROBIN CIR
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44143-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-969-5883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT
-----------------------------------------------------
Name | SARAH PAK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 215-427-8783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------