NPIMap

Organization Active NPI

Northeast Community Center for Mental Health-Mental Retardation I

  • Adult Mental Health Clinic/Center
  • Philadelphia, PA
National Provider Identifier
1306907704
Registry record updated Jul 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Mental Health Clinic/CenterTaxonomy code 261QM0850X
License
121890 Issued in PA
Legal business name
NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION I
Practice address
4641 Roosevelt Blvd
Philadelphia, PA 19124-2343
Phone
(215) 831-2800
Fax
(215) 831-2929
NPI assigned
Dec 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2014

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

Authorized official

Name
David ComoNPI 1497991202
Title
Executive Director
Phone
(215) 831-2800

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Mental Health Clinic/Center 261QM0850X 121890 PA Primary
Adolescent and Children Mental Health Clinic/Center 261QM0855X 121890 PA

Addresses

Primary practice location

4641 Roosevelt Blvd
Philadelphia, PA 19124-2343

Mailing address

4641 Roosevelt Blvd
Philadelphia, PA 19124-2343
Phone (215) 831-2800

Other identifiers 3

IdentifierTypeStateIssuer
769146OtherPAMEDICARE PTAN
1000034170051MedicaidPA
169773OtherPAMEDICARE PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040421001023 PA Part B Supplier - Clinic/Group Practice 9931195450 Receives reassigned benefits from 4 practitioners
Practice locations: Philadelphia, PA
O20040421001067 PA Part B Supplier - Clinic/Group Practice 9931195450 Receives reassigned benefits from 4 practitioners
Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory
Tax ID family
Northeast Community Center for Mental Health Mental Retardation22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

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

View all 21

Locations

4641 E Roosevelt Blvd
Philadelphia, PA 19124
Phone (215) 831-4600

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1165881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1404864000000",
    "number": "1306907704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4641 ROOSEVELT BLVD",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191242343",
            "telephone_number": "215-831-2800",
            "fax_number": "215-831-2929"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4641 ROOSEVELT BLVD",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191242343",
            "telephone_number": "215-831-2800",
            "fax_number": "215-831-2929"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION I",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-12",
        "last_updated": "2014-07-09",
        "status": "A",
        "authorized_official_last_name": "COMO",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "215-831-2800"
    },
    "taxonomies": [
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "PA",
            "license": "121890",
            "primary": true
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "PA",
            "license": "121890",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "769146",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1000034170051",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "169773",
            "state": "PA"
        }
    ],
    "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 Jul 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.