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PED393303-18 THE CHILDREN'S HOSPITAL OF PHILADELPHIA (Terminated)
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Main Details
Name
THE CHILDREN'S HOSPITAL OF PHILADELPHIA
Subdivision Name
Botox Therapy at Exton - Botox Therapy
Type
Children's Hospital
Rural
No
340B ID
PED393303-18
Medicare Provider Number
393303
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/13/2018
Participating Start Date
10/1/2018
Participating Approval Date
8/17/2018
Last Recertification Date
8/22/2024
Termination Date
Termination Reason
4/1/2025
Business decision by the Covered Entity
Contacts
Authorizing Official
Children's Hospital of Philadelphia
Jan Pieter Boswinkel, Senior Vice President & Chief Operating Officer, Hospital Operations
(215) 590-3055
Primary Contact
Children's Hospital of Philadelphia
Richard J. Dyke, Director of Pharmacy Business Operations
(267) 426-5834
Addresses
Street Address
481 John Young Way
Oaklands Corporate Center
Exton, PA 19341
Billing Address
The Children’s Hospital of Philadelphia
PO Box 2015
Secaucus, NJ 07096-2015
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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