1457354516 NPI number — DR. CLARENCE J VINCENT M.D.

Table of content: DR. CLARENCE J VINCENT M.D. (NPI 1457354516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457354516 NPI number — DR. CLARENCE J VINCENT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINCENT
Provider First Name:
CLARENCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1457354516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 808
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMBERLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21501-0808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-724-1646
Provider Business Mailing Address Fax Number:
301-724-7429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
952 SETON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-1950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-777-3522
Provider Business Practice Location Address Fax Number:
301-777-1902
Provider Enumeration Date:
05/23/2005

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: 174400000X , with the licence number:  D0017474 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001717208 . This is a "MT ST BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: J2490005 . This is a "GHMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1012103550001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0086105000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 411501500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: J2480005 . This is a "GHMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: P00139754 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com