NPIMap

Organization Active NPI

Dedicated Pennsylvania Holding, LLC

Doing business as Dedicated Pennsylvania Mayfair

  • Specialist
  • Philadelphia, PA
National Provider Identifier
1477053569
Registry record updated Mar 27, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
DEDICATED PENNSYLVANIA HOLDING, LLC
Doing business as
Dedicated Pennsylvania Mayfair
Practice address
6431 Sackett St
Philadelphia, PA 19149-3118
Phone
(305) 628-6117
Fax
(305) 363-5989
NPI assigned
Feb 15, 2018
Last updated
Mar 27, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
DEDICATED PENNSYLVANIA MAYFAIRAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 27, 2018

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

Authorized official

Name
Mr. Raymond Jimenez
Title
Director of Client Services
Phone
(786) 870-4039

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 174400000X Primary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X
Primary Care Clinic/Center 261QP2300X
Non-Pharmacy Dispensing Site 332900000X

Addresses

Primary practice location

6431 Sackett St
Philadelphia, PA 19149-3118

Mailing address

1395 N.W/ 167TH Street
Payer Enrollment Department
Miami Gardens, FL 33169
Phone (786) 870-4039

Other names 1

  • Dedicated Pennsylvania Mayfair Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180308000694 PA Part B Supplier - Clinic/Group Practice 4688935653 Receives reassigned benefits from 63 practitioners
4 other NPIs on this enrollment
Practice locations: Philadelphia, PA

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Dedicated PA Holding LLC

Locations

5675 N Front St
Ste 141
Philadelphia, PA 19120
Phone (267) 338-3411

Practitioners & affiliated clinicians

Practitioners 66

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 66

NPI Registry JSON

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

{
    "created_epoch": "1518652800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1522108800000",
    "number": "1477053569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1395 N.W/ 167TH STREET",
            "address_2": "PAYER ENROLLMENT DEPARTMENT",
            "city": "MIAMI GARDENS",
            "state": "FL",
            "postal_code": "33169",
            "telephone_number": "786-870-4039",
            "fax_number": "786-870-4039"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6431 SACKETT ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191493118",
            "telephone_number": "305-628-6117",
            "fax_number": "305-363-5989"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEDICATED PENNSYLVANIA HOLDING, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEDICATED PENNSYLVANIA MAYFAIR",
        "enumeration_date": "2018-02-15",
        "last_updated": "2018-03-27",
        "status": "A",
        "authorized_official_last_name": "JIMENEZ",
        "authorized_official_first_name": "RAYMOND",
        "authorized_official_title_or_position": "DIRECTOR OF CLIENT SERVICES",
        "authorized_official_telephone_number": "786-870-4039",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dedicated Pennsylvania Mayfair",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Dedicated Pennsylvania Mayfair",
            "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 Mar 27, 2018; 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.