Provider Demographics
NPI:1396079695
Name:JEFFERSON HEADACHE CENTER
Entity type:Organization
Organization Name:JEFFERSON HEADACHE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GUILD
Authorized Official - Suffix:
Authorized Official - Credentials:DIRECTOR, OPERATIONS
Authorized Official - Phone:215-955-2212
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:SUITE 8130 GIBBON BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-2727
Mailing Address - Fax:215-955-6682
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:SUITE 8130 GIBBON BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-2727
Practice Address - Fax:215-955-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA438132282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA438132OtherMEDICAL LICENCE NUMBER