NPIMap

Organization Active NPI

Innovage Pennsylvania Life, LLC

  • PACE Provider Organization
  • Philadelphia, PA
National Provider Identifier
1467056655
Registry record updated Nov 28, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
PACE Provider OrganizationTaxonomy code 251T00000X
Legal business name
INNOVAGE PENNSYLVANIA LIFE, LLC
Practice address
5364 Jackson St
Philadelphia, PA 19124-1565
Phone
(215) 288-3303
NPI assigned
Nov 28, 2020
Organization subpart
Yes
Parent organization
INNOVAGE PENNSYLVANIA LIFE, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 28, 2020

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

Authorized official

Name
Lezlie Corbin
Title
Credentialing Coordinator
Phone
(215) 734-9587

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PACE Provider Organization 251T00000X Primary

Addresses

Primary practice location

5364 Jackson St
Philadelphia, PA 19124-1565

Mailing address

8950 E Lowry Blvd
Denver, CO 80230-7030
Phone (215) 734-9587

Other identifiers 1

IdentifierTypeStateIssuer
101734256-0004MedicaidPA

Other names 1

  • InnovAge Pennsylvania LIFE - St. Bart's Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D2145232Innovage Pennsylvania Life5364 Jackson Street, Philadelphia, PA 19124Certificate of waiverMar 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
Innovage Pennsylvania Life LLC6 organizations share this tax ID, including this one
Part of
Innovage Pennsylvania Life LLC

Other organizations with this tax ID 5

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

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 1

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": "1606521600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1606521600000",
    "number": "1467056655",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8950 E LOWRY BLVD",
            "city": "DENVER",
            "state": "CO",
            "postal_code": "802307030",
            "telephone_number": "215-734-9587"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5364 JACKSON ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191241565",
            "telephone_number": "215-288-3303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNOVAGE PENNSYLVANIA LIFE, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "INNOVAGE PENNSYLVANIA LIFE, LLC",
        "enumeration_date": "2020-11-28",
        "last_updated": "2020-11-28",
        "certification_date": "2020-11-28",
        "status": "A",
        "authorized_official_last_name": "CORBIN",
        "authorized_official_first_name": "LEZLIE",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "215-734-9587"
    },
    "taxonomies": [
        {
            "code": "251T00000X",
            "taxonomy_group": "",
            "desc": "Program of All-Inclusive Care for the Elderly (PACE) Provider Organization",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "101734256-0004",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "InnovAge Pennsylvania LIFE - St. Bart's",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Nov 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.