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General NPI Number Information
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NPI Number | 1942703137
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Entity Type | Organization
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Legal Business Name | DEDICATED PENNSYLVANIA HOLDING, LLC
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 03/14/2018
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Provider Practice Location Address
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Address Line | 1575 N 52ND ST STE S-3
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City | PHILADELPHIA
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State | PA
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Zip | 19131-4736
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Country | US
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Telephone | 305-628-6117
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Fax |
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Provider Business Mailing Address
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Address Line | 1395 N.W/ 167TH STREET PAYER ENROLLMENT DEPARTMENT
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City | MIAMI GARDENS
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State | FL
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Zip | 33169
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Country | US
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Telephone | 786-870-4039
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Fax | 786-870-4039
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Authorized Official
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Title or Position | DIRECTOR OF CLIENT SVCS
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Name | RAYMOND JIMENEZ
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Credential |
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Telephone | 786-870-4039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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