NPIMap

Organization Active NPI

Penncare-J. Edwin Wood Clinic

  • Non-Pharmacy Dispensing Site
  • Philadelphia, PA
National Provider Identifier
1104967918
Registry record updated Dec 4, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Non-Pharmacy Dispensing SiteTaxonomy code 332900000X
License
OS012672 Issued in PA
Legal business name
PENNCARE-J. EDWIN WOOD CLINIC
Practice address
700 Spruce St
304
Philadelphia, PA 19106-4022
Phone
(215) 829-3532
NPI assigned
Feb 12, 2007
Organization subpart
Yes
Parent organization
MEDVANTX, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 4, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kenny Heine
Title
Director of Operations
Phone
(858) 625-2990

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Pharmacy Dispensing Site 332900000X OS012672 PA Primary

Addresses

Primary practice location

700 Spruce St
304
Philadelphia, PA 19106-4022

Mailing address

5626 Oberlin Dr
Suite 110
San Diego, CA 92121-1705

National Provider Directory

National Provider Directory
Tax ID family
Penncare-Pennsylvania Hospitalist Associates13 organizations share this tax ID, including this one
Part of
Tri - State Medical Group Inc

Other organizations with this tax ID 12

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1354579200000",
    "number": "1104967918",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5626 OBERLIN DR",
            "address_2": "SUITE 110",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921211705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 SPRUCE ST",
            "address_2": "304",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191064022",
            "telephone_number": "215-829-3532"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNCARE-J. EDWIN WOOD CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC.",
        "enumeration_date": "2007-02-12",
        "last_updated": "2012-12-04",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "KENNY",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "858-625-2990"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "PA",
            "license": "OS012672",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.