MEDICARE: PASSAVANT MEMORIAL HOMES

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	163W00000X	Registered Nurse
2	164W00000X	Licensed Practical Nurse
3	251S00000X	Community/Behavioral Health Agency	439240	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	100001216	OTHER	PA	MASTER PROVIDER INDEX

General Provider Information

NPI Number	:	1215489745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PASSAVANT MEMORIAL HOMES

Provider Business Mailing Address
First Line	:	100 PASSAVANT WAY
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15238-1318
Country	:	US
Telephone Number	:	412-820-1010
Fax Number	:	412-820-9246

Provider Business Practice Location Address
First Line	:	2550 EISENHOWER AVEUNE
Second Line	:
City	:	NORRISTOWN
State	:	PA
Zip	:	19403-2331
Country	:	US
Telephone Number	:	412-820-1010
Fax Number	:	412-820-9246

Authorized Official
Title or Position	:	UTILIZATION COORDINATOR
Name	:	MICHELLE BROWN
Credential	:
Telephone Number	:	412-820-1010

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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