1093863789 NPI number — HEALTHSOURCE OF BETHLEHEM LLC

Table of content: (NPI 1093863789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093863789 NPI number — HEALTHSOURCE OF BETHLEHEM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSOURCE OF BETHLEHEM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1093863789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3864 COURTNEY ST
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18017-8987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-282-1644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3864 COURTNEY ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18017-8987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-282-1644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HURON
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
484-282-1633

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC005305L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NR0400X , with the licence number: AJ005305L , 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)