1619921277 NPI number — CANTERBURY OF SHEPHERDSTOWN, LP

Table of content: (NPI 1619921277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619921277 NPI number — CANTERBURY OF SHEPHERDSTOWN, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANTERBURY OF SHEPHERDSTOWN, LP
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:
CANTERBURY CENTER
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:
1619921277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
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:
610-925-4351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 MADDEX DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEPHERDSTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25443-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-876-9422
Provider Business Practice Location Address Fax Number:
304-876-6869
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DROPESKEY
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE MANAGER
Authorized Official Telephone Number:
610-925-4231

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  133 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3126610 . This is a "AETNA - HMO" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 02SS . This is a "CAREFIRST - PROV/INQ #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 268528 . This is a "UNITED HEALTHCARE-MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 000399209 . This is a "MOUNTAIN STATE BC/BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: PX9 . This is a "CAREFIRST - BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0003509000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: PX9 . This is a "CAREFIRST - IND/PPO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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