Provider Demographics
NPI:1396455945
Name:THE WEDGE MEDICAL CENTER, P.C.
Entity type:Organization
Organization Name:THE WEDGE MEDICAL CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TAKISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-276-3922
Mailing Address - Street 1:6711 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-2841
Mailing Address - Country:US
Mailing Address - Phone:215-276-3922
Mailing Address - Fax:215-276-1249
Practice Address - Street 1:5520 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5328
Practice Address - Country:US
Practice Address - Phone:215-276-3922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE WEDGE MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100728192Medicaid