1215962774 NPI number — DR. BARRY A WAHNER DC

Table of content: DR. BARRY A WAHNER DC (NPI 1215962774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215962774 NPI number — DR. BARRY A WAHNER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAHNER
Provider First Name:
BARRY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1215962774
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4931 WISSAHICKON AVE
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19144-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-842-2227
Provider Business Mailing Address Fax Number:
215-842-2229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4931 WISSAHICKON AVE
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19144-4800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-842-2227
Provider Business Practice Location Address Fax Number:
215-842-2229
Provider Enumeration Date:
07/12/2006

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:  DC004737L , 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: 0526039000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1296428 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".