1154486421 NPI number — STONESTOWN PEDIATRICS

Table of content: (NPI 1154486421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154486421 NPI number — STONESTOWN PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONESTOWN PEDIATRICS
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:
STONESTOWN PEDIATRIC MEDICAL OFFICE
Provider Other Organization Name Type Code:
4
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:
1154486421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
595 BUCKINGHAM WAY
Provider Second Line Business Mailing Address:
#355
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94132-1909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-566-2727
Provider Business Mailing Address Fax Number:
415-566-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
595 BUCKINGHAM WAY
Provider Second Line Business Practice Location Address:
#355
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94132-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-566-2727
Provider Business Practice Location Address Fax Number:
415-566-0081
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SOLLOD
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
415-566-2727

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  C27394 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: FNP30374 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: YYY20778Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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