1780660316 NPI number — FRED STUTMAN MD

Table of content: FRED STUTMAN MD (NPI 1780660316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780660316 NPI number — FRED STUTMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUTMAN
Provider First Name:
FRED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780660316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 820933
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-0933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-632-1400
Provider Business Mailing Address Fax Number:
215-632-2176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 NEWBERRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19154-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-632-1400
Provider Business Practice Location Address Fax Number:
215-632-2176
Provider Enumeration Date:
12/15/2005

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: 207Q00000X , with the licence number:  MD007124E , 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)

  • Identifier: 000612309 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0047315 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00208191 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 597586 . This is a "MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1081468 . This is a "KEYSTONE MERCY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 714 . This is a "BRAVO HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0058304000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 016618 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2Y0397 . This is a "HEALTH NET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4076190 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P495461 . This is a "OXFORD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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