1760576938 NPI number — MS. MARY M MCMENAMIN RD,LDN

Table of content: MS. MARY M MCMENAMIN RD,LDN (NPI 1760576938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760576938 NPI number — MS. MARY M MCMENAMIN RD,LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMENAMIN
Provider First Name:
MARY
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD,LDN
Provider Gender Code:
F

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:
1760576938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 CRESTVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18966-2159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-776-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 N BETHLEHEM PIKE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LOWER GWYNEDD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19002-2655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-283-2833
Provider Business Practice Location Address Fax Number:
215-283-1919
Provider Enumeration Date:
10/03/2006

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: 133V00000X , with the licence number:  DN003270 , 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)