NPIMap

Organization Active NPI

Philadelphia Fight

  • Federally Qualified Health Center (FQHC)
  • Philadelphia, PA
National Provider Identifier
1487082608
Registry record updated Nov 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PHILADELPHIA FIGHT
Practice address
1233 Locust St FL 4
Philadelphia, PA 19107-5459
Phone
(215) 790-1788
Fax
(215) 732-5490
NPI assigned
Oct 25, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 3, 2022

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

Authorized official

Name
Jose J Virella
Title
Cfo
Phone
(917) 842-3011

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1233 Locust St FL 4
Philadelphia, PA 19107-5459

Mailing address

1233 Locust St FL 3
Philadelphia, PA 19107-5400
Phone (215) 985-4448

Other practice location 1

1211 Chestnut St Fl 6
Philadelphia, PA 19107-4103
Phone (215) 985-4448

Other practice location 2

1207 Chestnut St Fl 3
Philadelphia, PA 19107-4131
Phone (267) 725-0252

Other practice location 3

1207 Chestnut St Fl 4
Philadelphia, PA 19107-4131
Phone (215) 525-3046

Other practice location 4

315 S Broad St
Philadelphia, PA 19107-5213
Phone (267) 725-0252

Other practice location 5

1211 Chestnut St Fl 6
Philadelphia, PA 19107-4103
Phone (215) 985-4448

Other practice location 6

1233 Locust St Fl 4
Philadelphia, PA 19107-5459
Phone (215) 790-1788

Other practice location 7

1207 Chestnut St Fl 5
Philadelphia, PA 19107-4131
Phone (215) 525-8600

Other practice location 8

1207 Chestnut St Fl 5
Philadelphia, PA 19107-4131
Phone (215) 525-8600

Other identifiers 1

IdentifierTypeStateIssuer
100747222MedicaidPA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA6 enrollments

Enrollment records 6

Enrollment IDStateProvider typePAC IDDetails
O20040119000746 PA Part B Supplier - Clinic/Group Practice 9032010319 Receives reassigned benefits from 53 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Philadelphia, PA
O20140529000237 PA Part A Provider - Federally Qualified Health Center (FQHC) 9032010319 Practice locations: Philadelphia, PA
O20150716002501 PA Part A Provider - Federally Qualified Health Center (FQHC) 9032010319 Practice locations: Philadelphia, PA
O20150805007571 PA Part A Provider - Federally Qualified Health Center (FQHC) 9032010319 Practice locations: Philadelphia, PA
O20180209000595 PA Part A Provider - Federally Qualified Health Center (FQHC) 9032010319 Practice locations: Philadelphia, PA
O20180924003227 PA Part A Provider - Federally Qualified Health Center (FQHC) 9032010319 Practice locations: Philadelphia, PA

NPI to CCN mapping 5

The Medicare certification numbers (CCNs) connected to NPI 1487082608. Details of each certification follow.

Federally qualified health center certification: CCN 391042

Legal name
PHILADELPHIA FIGHT
Doing business as
JONATHAN LAX TREATMENT CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 29, 2014
Last certification
May 29, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 1991 in PA
Enrollment address
1233 Locust Street
4TH and 5TH Floors
Philadelphia, PA 19107-5453

Federally qualified health center certification: CCN 391054

Legal name
PHILADELPHIA FIGHT
Doing business as
YHEP HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 30, 2015
Last certification
Jul 30, 2015
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 1, 1991 in PA
Enrollment address
1207 Chestnut St
FL 5
Philadelphia, PA 19107-4131

Federally qualified health center certification: CCN 391051

Legal name
PHILADELPHIA FIGHT
Doing business as
PHILADELPHIA FIGHT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 4, 2015
Last certification
Aug 4, 2015
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Incorporated
Apr 1, 1991 in PA
Enrollment address
1207 Chestnut St
Philadelphia, PA 19107-4131

Federally qualified health center certification: CCN 391105

Legal name
PHILADELPHIA FIGHT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 26, 2018
Last certification
Jan 26, 2018
Ownership / control type
For profit – corporation
Organization structure
LLCNon-profit
Incorporated
Oct 15, 1990 in PA
Enrollment address
315 S Broad St
Philadelphia, PA 19107-5213

Federally qualified health center certification: CCN 391120

Legal name
PHILADELPHIA FIGHT
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 25, 2018
Last certification
Sep 25, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 15, 1990 in PA
Enrollment address
1211 Chestnut St
Ste 605
Philadelphia, PA 19107-4117

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory

Locations

1233 Locust St
#45
Philadelphia, PA 19107

1211 Chestnut St
Ste 610
Philadelphia, PA 19107
Phone (215) 525-2686

1207 Chestnut St
Philadelphia, PA 19107
Phone (215) 525-8600

1233 Locust St
Fl 3
Philadelphia, PA 19107
Phone (267) 725-0252

1233 Locust St
Ste 500
Philadelphia, PA 19107
Phone (215) 790-1788

1417 Locust St
Fl 2
Philadelphia, PA 19102
Phone (215) 344-1632

2011 N Mascher St
Philadelphia, PA 19122
Phone (215) 525-8600

1207 Chestnut St
Fl 4
Philadelphia, PA 19107
Phone (215) 525-3046

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Teresa Trudeau Individual Operational/Managerial ControlBoard Member Oct 1, 2021
Corporate DirectorBoard Member Oct 1, 2018
Other Oct 1, 2018
Richard L Lombardo Individual Operational/Managerial ControlBoard Treasurer Oct 1, 2002
Corporate DirectorBoard Treasurer Oct 1, 2002
Other Oct 1, 2002
Andrea Johnson Individual Corporate DirectorBoard Member Aug 1, 2024
Corporate OfficerBoard Member Aug 1, 2024
Kevin J Cotton Individual Operational/Managerial ControlBoard Member Jul 17, 2013
Corporate DirectorBoard Member Oct 1, 2013
OtherBoard Member Oct 1, 2013
David Thomas Individual Operational/Managerial ControlBoard Member Oct 1, 2021
Corporate DirectorBoard Member Oct 1, 2016
Other Oct 1, 2016
Mary Thibodeau Individual Corporate OfficerCfo Nov 1, 2023
Corporate DirectorCfo Nov 1, 2023
W-2 Managing EmployeeCfo Nov 1, 2023
Corporate OfficerCfo Jan 1, 2024
Corporate DirectorCfo Jan 1, 2024
W-2 Managing Employee Jan 1, 2024
Dexter Hogan Individual Operational/Managerial ControlBoard Member Oct 1, 2021
Corporate DirectorBoard Member Oct 1, 2017
Other Oct 1, 2017
Luis J Montaner Individual Operational/Managerial ControlBoard Member Oct 1, 1994
Corporate DirectorBoard Member Oct 1, 1994
Other Oct 1, 1994
Wilson Goode Individual Operational/Managerial ControlBoard Member Oct 1, 2021
Corporate DirectorBoard Member Oct 1, 1994
Other Oct 1, 1994
Andy a St Remy Individual Operational/Managerial ControlBoard Secretary Jul 17, 2013
Corporate DirectorBoard Secretary Oct 1, 2013
Other Oct 1, 2013
Susan Thomas Individual Operational/Managerial ControlBoard Member Oct 1, 2021
Corporate DirectorBoard Member Oct 1, 2015
Other Oct 1, 2015
Ernest L McNear Individual Operational/Managerial ControlBoard President Jul 1, 2002
Corporate DirectorBoard President Oct 1, 2002
Other Oct 1, 2002
Philadelphia Fight Organization, Philadelphia, PA Created for acquisition 5% Or Greater Direct Ownership Interest Oct 1, 1990 100%
Operational/Managerial Control Jul 1, 2002 100%
5% Or Greater Direct Ownership Interest Oct 1, 1990
Operational/Managerial Control Jul 1, 2002
Lovada Washington Individual Corporate DirectorBoard Vice President Oct 1, 2014
Other Oct 1, 2014
Grace Rutha Individual Corporate DirectorBoard Member Oct 1, 2021
Other Oct 1, 2021
Scott M Wilds Individual Corporate DirectorBoard Member Oct 1, 1992
Other Oct 1, 1992
Scott a Drake Individual Other Oct 1, 2009
Jane Shull Individual Corporate OfficerCeo Jul 1, 2018
W-2 Managing Employee Jul 1, 2018

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Philadelphia Fight
    • Internal Medicine Physician
    • Philadelphia, PA
    • NPI 1760507859

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 43

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 43

NPI Registry JSON

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

{
    "created_epoch": "1382659200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1667433600000",
    "number": "1487082608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1233 LOCUST ST FL 3",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075400",
            "telephone_number": "215-985-4448",
            "fax_number": "215-732-1145"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1233 LOCUST ST FL 4",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075459",
            "telephone_number": "215-790-1788",
            "fax_number": "215-732-5490"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1211 Chestnut St Fl 6",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074103",
            "country_code": "US",
            "telephone_number": "215-985-4448",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1207 Chestnut St Fl 3",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074131",
            "country_code": "US",
            "telephone_number": "267-725-0252",
            "fax_number": "215-732-1046",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1207 Chestnut St Fl 4",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074131",
            "country_code": "US",
            "telephone_number": "215-525-3046",
            "fax_number": "215-567-1617",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "315 S Broad St",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191075213",
            "country_code": "US",
            "telephone_number": "267-725-0252",
            "fax_number": "215-732-1046",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1211 Chestnut St Fl 6",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074103",
            "country_code": "US",
            "telephone_number": "215-985-4448",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1233 Locust St Fl 4",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191075459",
            "country_code": "US",
            "telephone_number": "215-790-1788",
            "fax_number": "215-732-5490",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1207 Chestnut St Fl 5",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074131",
            "country_code": "US",
            "telephone_number": "215-525-8600",
            "fax_number": "215-564-8606",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1207 Chestnut St Fl 5",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191074131",
            "country_code": "US",
            "telephone_number": "215-525-8600",
            "fax_number": "215-732-1145",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PHILADELPHIA FIGHT",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-25",
        "last_updated": "2022-11-03",
        "certification_date": "2022-11-03",
        "status": "A",
        "authorized_official_last_name": "VIRELLA",
        "authorized_official_first_name": "JOSE",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "917-842-3011"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100747222",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

Verify at the official NPI Registry.