1366468134 NPI number — DR. JEFFREY SCOTT SHOSTACK PSY.D.

Table of content: DR. JEFFREY SCOTT SHOSTACK PSY.D. (NPI 1366468134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366468134 NPI number — DR. JEFFREY SCOTT SHOSTACK PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOSTACK
Provider First Name:
JEFFREY
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
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:
1366468134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 ARCH ST
Provider Second Line Business Mailing Address:
APT. 401
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19103-1328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-825-7645
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
246 W STREET RD
Provider Second Line Business Practice Location Address:
SUITE 4A
Provider Business Practice Location Address City Name:
WARMINSTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18974-3228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-825-7645
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

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: 103TC0700X , with the licence number:  PS008603L , 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)





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