MEDICARE: INNOVAGE PENNSYLVANIA LIFE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251T00000X	PACE Provider Organization

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013519735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVAGE PENNSYLVANIA LIFE, LLC

Provider Business Mailing Address
First Line	:	8950 E LOWRY BLVD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80230-7030
Country	:	US
Telephone Number	:	303-912-7193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1940 W ALLEGHENY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-1614
Country	:	US
Telephone Number	:	267-335-1500
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	GAYLE M WASHINGTON
Credential	:
Telephone Number	:	303-912-7193

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	11/09/2020

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