=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629023593
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY HOMECARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 02/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8118 OLD YORK RD SUITE D
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-635-3151
-----------------------------------------------------
Fax | 215-635-3165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8118 OLD YORK RD SUITE D
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-635-3151
-----------------------------------------------------
Fax | 215-635-3165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CCO
-----------------------------------------------------
Name | LISA GILL
-----------------------------------------------------
Credential | DNP, CRNP
-----------------------------------------------------
Telephone | 215-635-3151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------