1356582035 NPI number — DESIGNING HEALTH PA

Table of content: (NPI 1356582035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356582035 NPI number — DESIGNING HEALTH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESIGNING HEALTH PA
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:
MAIN STREET MEDICAL
Provider Other Organization Name Type Code:
3
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:
1356582035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2603 MAIN DR
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72704-5278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-571-4325
Provider Business Mailing Address Fax Number:
479-571-4329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2603 MAIN DR
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72704-5278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-571-4325
Provider Business Practice Location Address Fax Number:
479-571-4329
Provider Enumeration Date:
03/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FEDOSKY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
479-571-4325

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E2717 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: E0546 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1710993654 . This is a "NPPES - INDIVIDUAL NPI NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 179094002 . This is a "DESIGNING HEALTH, PA MEDICAID ORGANIZATIONAL NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 167302001 . This is a "MEDICAID PERSONAL NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5G182 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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