Provider Demographics
| NPI: | 1881635704 |
|---|---|
| Name: | PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE |
| Entity type: | Organization |
| Organization Name: | PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | SR VP FOR ACADEMIC AFFAIRS AND DEAN |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | KENNETH |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | VEIT |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | DO |
| Authorized Official - Phone: | 215-871-6562 |
| Mailing Address - Street 1: | PO BOX 22383 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | NEW YORK |
| Mailing Address - State: | NY |
| Mailing Address - Zip Code: | 10087-2383 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 215-871-6562 |
| Mailing Address - Fax: | 215-871-6905 |
| Practice Address - Street 1: | 4190 CITY AVE |
| Practice Address - Street 2: | |
| Practice Address - City: | PHILADELPHIA |
| Practice Address - State: | PA |
| Practice Address - Zip Code: | 19131-1626 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 215-871-6562 |
| Practice Address - Fax: | 215-871-6781 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-06-10 |
| Last Update Date: | 2021-09-13 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 204D00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | Group - Multi-Specialty | |
| No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| PA | CC3119 | Other | RAIL ROAD MEDICARE |
| PA | 1007772030027 | Medicaid | |
| PA | 090051 | Medicare PIN | |
| PA | 089967 | Medicare PIN | |
| PA | 1007772030027 | Medicaid | |
| PA | 090109 | Medicare PIN | |
| PA | 150161 | Medicare PIN | |
| PA | 051648 | Medicare PIN | |
| PA | 597581 | Medicare PIN | |
| PA | 090051 | Medicare PIN | |
| PA | 778957 | Medicare PIN | |
| PA | CC3119 | Other | RAIL ROAD MEDICARE |
| PR | 100777203-0025 | Medicaid | |
| PA | 100777203-0021 | Medicaid | |
| PA | 597581 | Medicare PIN | |
| PA | 051648 | Medicare PIN | |
| PA | 089886 | Medicare PIN | |
| PA | 089967 | Medicare PIN |
