1417116112 NPI number — SUNBURY PRIMARY CARE PA

Table of content: (NPI 1417116112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417116112 NPI number — SUNBURY PRIMARY CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBURY PRIMARY CARE 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:
DIRIGO OFFICE
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:
1417116112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 921
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-0921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-942-7650
Provider Business Mailing Address Fax Number:
207-990-5583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 ALUMNI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORONO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04473-3479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-223-5674
Provider Business Practice Location Address Fax Number:
207-223-5675
Provider Enumeration Date:
06/06/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAVELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
207-942-7650

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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