MEDICARE: RUSSELL BYERS CHARTER SCHOOL

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	251300000X	Local Education Agency (LEA)		PA

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	:	1114015740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL BYERS CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	1191 ARCH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1403
Country	:	US
Telephone Number	:	215-972-1700
Fax Number	:	215-972-1701

Provider Business Practice Location Address
First Line	:	1191 ARCH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1403
Country	:	US
Telephone Number	:	215-972-1700
Fax Number	:	215-972-1701

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MR. GERALD L SANTILLI
Credential	:
Telephone Number	:	856-505-1300

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	08/22/2020

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