NPIMap

Organization Active NPI

Dedicated Pennsylvania Holding, LLC

  • Internal Medicine Physician
  • Philadelphia, PA
National Provider Identifier
1952804312
Registry record updated Mar 13, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
DEDICATED PENNSYLVANIA HOLDING, LLC
Practice address
2101 W Lehigh Ave Ste a
Philadelphia, PA 19132-2664
Phone
(305) 628-6117
Fax
(786) 870-4039
NPI assigned
Mar 13, 2018
Organization subpart
Yes
Parent organization
DEDICATED PENNSYLVANIA HOLDING, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 13, 2018

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

Authorized official

Name
Mr. Raymond Jimenez
Title
Dir of Client SVCS
Phone
(786) 870-4039

Specialties & licenses 4

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

Addresses

Primary practice location

2101 W Lehigh Ave Ste a
Philadelphia, PA 19132-2664

Mailing address

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

Other names 1

  • Dedicated Pennsylvania North Philadelphia Other name

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
This NPI is an additional NPI on the 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

1575 N 52nd St
Philadelphia, PA 19131
Phone (215) 747-6661

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 8

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": "1520899200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1520899200000",
    "number": "1952804312",
    "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": "2101 W LEHIGH AVE STE A",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191322664",
            "telephone_number": "305-628-6117",
            "fax_number": "786-870-4039"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEDICATED PENNSYLVANIA HOLDING, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEDICATED PENNSYLVANIA HOLDING, LLC",
        "enumeration_date": "2018-03-13",
        "last_updated": "2018-03-13",
        "status": "A",
        "authorized_official_last_name": "JIMENEZ",
        "authorized_official_first_name": "RAYMOND",
        "authorized_official_title_or_position": "DIR OF CLIENT SVCS",
        "authorized_official_telephone_number": "786-870-4039",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "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 North Philadelphia",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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 13, 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.