MEDICARE: WEST PHILADELPHIA COMMUNITY MH CONSORTIUM INC.

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	128620	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	:	1386761971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PHILADELPHIA COMMUNITY MH CONSORTIUM INC.

Provider Business Mailing Address
First Line	:	3801 MARKET ST
Second Line	:	SUITE 201
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3153
Country	:	US
Telephone Number	:	215-596-8100
Fax Number	:	215-382-4405

Provider Business Practice Location Address
First Line	:	5700 WILLOWS AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-4517
Country	:	US
Telephone Number	:	215-596-8100
Fax Number	:	218-382-4405

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	MR. JOHN F WHITE JR.
Credential	:
Telephone Number	:	215-596-8100

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	08/22/2020

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