1619274545 NPI number — 3330 WILKENS AVENUE OPERATIONS LLC

Table of content: (NPI 1619274545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619274545 NPI number — 3330 WILKENS AVENUE OPERATIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
3330 WILKENS AVENUE OPERATIONS LLC
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:
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:
1619274545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-925-4436
Provider Business Mailing Address Fax Number:
610-347-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 WILKENS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21229-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-525-1544
Provider Business Practice Location Address Fax Number:
410-646-4779
Provider Enumeration Date:
02/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
505-468-4752

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  30008 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 30008 , 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: 420461100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com