Provider Demographics
NPI:1669055349
Name:PENNSYLVANIA INTEGRATIVE CLINICAL SERVICES, INC.
Entity type:Organization
Organization Name:PENNSYLVANIA INTEGRATIVE CLINICAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-438-5827
Mailing Address - Street 1:41 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2668
Practice Address - Country:US
Practice Address - Phone:610-438-5827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No282J00000XHospitalsReligious Nonmedical Health Care Institution
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039062240001Medicaid