MEDICARE: CITY OF PHILADELPHIA

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	261QF0400X	Federally Qualified Health Center (FQHC)		PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	66692	OTHER	PA	HIGHMARK BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417064353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF PHILADELPHIA

Provider Business Mailing Address
First Line	:	1101 MARKET ST FL 10
Second Line	:	REVENUE MANAGEMENT
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-2911
Country	:	US
Telephone Number	:	215-685-5306
Fax Number	:	215-685-6848

Provider Business Practice Location Address
First Line	:	2840 W DAUPHIN ST
Second Line	:	STRAWBERRY MANSION HEALTH CTR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-4627
Country	:	US
Telephone Number	:	215-685-2403
Fax Number	:	215-685-6848

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	CHRISTINE GADDY
Credential	:
Telephone Number	:	215-685-6843

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	12/03/2019

Similar Medicare Providers

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Practice Location Address:

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Practice Fax: 215-685-2440

1275646218 — DR. SHASHI RAJ DIVAKER M.D.
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1124136007 — DR. TANYA DENICE MALONE D.O.
Practice Location Address:

2840 W DAUPHIN ST
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19132-4627

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Practice Location Address:

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19132-4627

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Practice Fax: 215-685-2440

1073618625 — EMMAH ANDY R.PH.
Practice Location Address:

2840 W DAUPHIN ST
PHILADELPHIA, PA
19132-4627

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Practice Fax:

1205998267 — MRS. JEANETTE L SKIPPER-THOMAS
Practice Location Address:

2840 W DAUPHIN ST
PHILADELPHIA, PA
19132-4627

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Directions to “CITY OF PHILADELPHIA ” Practice Location

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