1679873970 NPI number — MAENPAA SPORTS MEDICINE LLC

Table of content: (NPI 1679873970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679873970 NPI number — MAENPAA SPORTS MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAENPAA SPORTS MEDICINE 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:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1679873970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
486 KING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINGSWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08108-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-209-2912
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
829 SPRUCE ST
Provider Second Line Business Practice Location Address:
SUITE308
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-5752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-334-5346
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAENPAA
Authorized Official First Name:
GARATH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
610-209-2912

Provider Taxonomy Codes

  • Taxonomy code: 207RS0010X , with the licence number:  MD073775-L , 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)