1285995118 NPI number — MR. SHAWN JERMAINE SMALLS NURSE

Table of content: MR. SHAWN JERMAINE SMALLS NURSE (NPI 1285995118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285995118 NPI number — MR. SHAWN JERMAINE SMALLS NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALLS
Provider First Name:
SHAWN
Provider Middle Name:
JERMAINE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NURSE
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMALLS
Provider Other First Name:
SHAWN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NURSE
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1285995118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 HICKORY RD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
PLYMOUTH MEETING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19462-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-888-0588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 HICKORY RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
PLYMOUTH MEETING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19462-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-998-0469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2012

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: 164W00000X , with the licence number:  L2-0010853 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 164W00000X , with the licence number: PN278828 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 164W00000X . This is a "INDIVIDUAL PROVIDER" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 164W00000X . This is a "INDIVIDUAL PROVIDER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 164W00000X . This is a "INDIVIDUAL PROVIDER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".