1912962812 NPI number — MR. CRAIG S FAVA P.T.

Table of content: MR. CRAIG S FAVA P.T. (NPI 1912962812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912962812 NPI number — MR. CRAIG S FAVA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVA
Provider First Name:
CRAIG
Provider Middle Name:
S
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1912962812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 OAKVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19063-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-565-1671
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 S CHESTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SWARTHMORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19081-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-543-4605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2006

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:  PT-011552-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)

  • Identifier: 00872660000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7148219 . This is a "AETNA TRADITIONAL #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2582353 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".