1881650281 NPI number — MR. STANLEY T PETRICK MSPT

Table of content: MR. STANLEY T PETRICK MSPT (NPI 1881650281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881650281 NPI number — MR. STANLEY T PETRICK MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRICK
Provider First Name:
STANLEY
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1881650281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201B NORTH CHURCH STREET
Provider Second Line Business Mailing Address:
SUITE 307
Provider Business Mailing Address City Name:
HAZLE TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18202-1453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-455-7108
Provider Business Mailing Address Fax Number:
570-455-8835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201B NORTH CHURCH STREET
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
HAZLE TOWNSHIP
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18202-1453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-455-7108
Provider Business Practice Location Address Fax Number:
570-455-8835
Provider Enumeration Date:
04/25/2006

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: 225100000X , with the licence number:  PT011725L , 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: P00199564 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 230232 . This is a "HEALTH AMERICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 820635 . This is a "FIRST PRIORITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1230503 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50038360 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PE176517 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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