1063594570 NPI number — DR. JOHN E WOLFGANG D.C.

Table of content: DR. JOHN E WOLFGANG D.C. (NPI 1063594570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063594570 NPI number — DR. JOHN E WOLFGANG D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLFGANG
Provider First Name:
JOHN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063594570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
519 N 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CATAWISSA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17820-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-356-7747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1028 CENTRE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-875-1125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC007956L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001938398 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02856500 . This is a "CAPITOL BLUE CROSS #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 07781457 . This is a "MEDICAID CROSSOVER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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