| NPI |
1881635704 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
| Provider Organization Name Legal Business Name |
PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Practice Location Address |
4190 CITY AVE |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
PHILADELPHIA |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
PA |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
191311626 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
2158716562 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
2158716781 |
The fax number associated with the location
address of the provider being identified. |
| Provider Enumeration Date |
6/10/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
9/13/2021 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Authorized Official Last Name |
VEIT |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
KENNETH |
The first name of the authorized official. |
| Authorized Official Middle Name |
J |
The middle name of the authorized official. |
| Authorized Official Title or Position |
SR VP FOR ACADEMIC AFFAIRS AND DEAN |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
2158716562 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
103T00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
| Healthcare Provider Taxonomy Code 2 |
204D00000X |
|
| Healthcare Provider Primary Taxonomy Switch 2 |
N |
|
| Healthcare Provider Taxonomy Code 3 |
207QG0300X |
|
| Healthcare Provider Primary Taxonomy Switch 3 |
N |
|
| Healthcare Provider Taxonomy Code 4 |
207R00000X |
|
| Healthcare Provider Primary Taxonomy Switch 4 |
N |
|
| Healthcare Provider Taxonomy Code 5 |
207RC0200X |
|
| Healthcare Provider Primary Taxonomy Switch 5 |
N |
|
| Healthcare Provider Taxonomy Code 6 |
207RP1001X |
|
| Healthcare Provider Primary Taxonomy Switch 6 |
N |
|
| Healthcare Provider Taxonomy Code 7 |
207X00000X |
|
| Healthcare Provider Primary Taxonomy Switch 7 |
N |
|
| Healthcare Provider Taxonomy Code 8 |
208600000X |
|
| Healthcare Provider Primary Taxonomy Switch 8 |
N |
|
| Healthcare Provider Taxonomy Code 9 |
363A00000X |
|
| Healthcare Provider Primary Taxonomy Switch 9 |
N |
|
| Healthcare Provider Taxonomy Code 10 |
208000000X |
|
| Healthcare Provider Primary Taxonomy Switch 10 |
N |
|
| Healthcare Provider Taxonomy Code 11 |
208100000X |
|
| Healthcare Provider Primary Taxonomy Switch 11 |
N |
|
| Healthcare Provider Taxonomy Code 12 |
207Q00000X |
|
| Healthcare Provider Primary Taxonomy Switch 12 |
Y |
|
| Other Provider Identifier 1 |
1007772030027 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
PA |
|
| Other Provider Identifier 2 |
CC3119 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 2 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 2 |
PA |
|
| Other Provider Identifier Issuer 2 |
RAIL ROAD MEDICARE |
|
| Is Organization Subpart |
Y |
|
| Parent Organization LBN |
PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE |
|
| Parent Organization TIN |
|
|
| Authorized Official Credential Text |
DO |
|
| Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 2 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 3 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 4 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 5 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 6 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 7 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 8 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 9 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 10 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 11 |
193200000X MULTI-SPECIALTY GROUP |
|
| Healthcare Provider Taxonomy Group 12 |
193200000X MULTI-SPECIALTY GROUP |
|
| NPI Certification Date |
9/13/2021 |
|