Provider Demographics
NPI:1487768123
Name:ELWYN OF PENNSYLVANIA AND DELAWARE
Entity type:Organization
Organization Name:ELWYN OF PENNSYLVANIA AND DELAWARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PAYER CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-639-6932
Mailing Address - Street 1:4025 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3054
Mailing Address - Country:US
Mailing Address - Phone:215-222-5066
Mailing Address - Fax:215-222-5143
Practice Address - Street 1:4025 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3054
Practice Address - Country:US
Practice Address - Phone:215-222-5066
Practice Address - Fax:215-222-5143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000021240225Medicaid