MEDICARE: COMMUNITY COUNCIL

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	251S00000X	Community/Behavioral Health Agency	121630	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	:	1407079742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNCIL

Provider Business Mailing Address
First Line	:	4900 WYALUSING AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-5127
Country	:	US
Telephone Number	:	215-473-7033
Fax Number	:	215-933-6926

Provider Business Practice Location Address
First Line	:	2498 W DIAMOND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-1311
Country	:	US
Telephone Number	:	215-684-5081
Fax Number	:	215-684-8995

Authorized Official
Title or Position	:	CHIEF INFORMATION OFFICER
Name	:	JAMES PAIGE
Credential	:
Telephone Number	:	215-473-7033

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	04/02/2008

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