1265571426 NPI number — NICHOLAS J FEDORKA DMD PC

Table of content: DR. JOSEPH T LEE MD (NPI 1821093584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265571426 NPI number — NICHOLAS J FEDORKA DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLAS J FEDORKA DMD PC
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:
1265571426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 POPLAR STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-333-4454
Provider Business Mailing Address Fax Number:
814-336-3357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 POPLAR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-333-4454
Provider Business Practice Location Address Fax Number:
814-336-3357
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FEDORKA
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
OWNER ORAL & MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
814-336-3357

Provider Taxonomy Codes

  • Taxonomy code: 1223P0106X , with the licence number:  DS023205L , 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: 0008854040002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0008854040004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134372 . This is a "HIGHMARK BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103082 . This is a "UPMC" identifier . This identifiers is of the category "OTHER".




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