1124236708 NPI number — BLOOMSBURG PHYSICIAN SERVICES

Table of content: (NPI 1124236708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124236708 NPI number — BLOOMSBURG PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMSBURG PHYSICIAN SERVICES
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:
BLOOMSBURG PHYSICIAN SERVICES OBGYN
Provider Other Organization Name Type Code:
5
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:
1124236708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 GLENN AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-387-2474
Provider Business Mailing Address Fax Number:
570-387-2397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 GLENN AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-387-2474
Provider Business Practice Location Address Fax Number:
570-387-2397
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEVITO
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
570-387-2148

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1015090000002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 94984 . This is a "GHP NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1388085 . This is a "HIGHMARK NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50052725 . This is a "CBC NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 819545 . This is a "FIRST PRIORITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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