1245306489 NPI number — SPINAL CARE PAIN ASSOCIATES, P.C.

Table of content: (NPI 1245306489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245306489 NPI number — SPINAL CARE PAIN ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINAL CARE PAIN ASSOCIATES, P.C.
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:
1245306489
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:
2410 S BROAD ST
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19145-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-462-6600
Provider Business Mailing Address Fax Number:
215-462-2650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2410 S BROAD ST
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-462-6600
Provider Business Practice Location Address Fax Number:
215-462-2650
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
215-462-6600

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2992866 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2100648000 . This is a "KEYSTONE EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30001785 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 347886100 . This is a "US DEPT OF LABOR OWCP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 22210 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1413937 . This is a "ALL BLUE SHIELDS, AMERIHL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 93900 . This is a "AMERICHOICE OF PENN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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