Organization
DEDICATED PENNSYLVANIA HOLDING, LLC
Active
Parent organization
DEDICATED PENNSYLVANIA MAYFAIR
Other names
Dedicated Pennsylvania Mayfair
Organization subpart
Yes
Provider details
NPI number
Legal business name
DEDICATED PENNSYLVANIA MAYFAIR
Authorized official
MR. RAYMOND JIMENEZ (DIRECTOR OF CLIENT SERVICES)
(786) 870-4039
Entity
Organization
Contact information
Practice address
6431 SACKETT ST, PHILADELPHIA, PA 19149-3118
(305) 628-6117
(305) 363-5989
Mailing address
1395 N.W/ 167TH STREET, PAYER ENROLLMENT DEPARTMENT, MIAMI GARDENS, FL 33169
(786) 870-4039
(786) 870-4039
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
207R00000X
Internal Medicine Physician
—
—
261QP2300X
Primary Care Clinic/Center
—
—
332900000X
Non-Pharmacy Dispensing Site
—
—
Other
Enumeration date
02/15/2018
Last updated
03/27/2018
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