1942357454 NPI number — PENNSYLVANIA DERMATOLOGY GROUP, P.C.

Table of content: (NPI 1942357454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942357454 NPI number — PENNSYLVANIA DERMATOLOGY GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNSYLVANIA DERMATOLOGY GROUP, P.C.
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:
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:
1942357454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 HUNTINGDON PIKE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
HUNTINGDON VALLEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19006-6130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-947-7500
Provider Business Mailing Address Fax Number:
215-947-7501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 HUNTINGDON PIKE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
HUNTINGDON VALLEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19006-6130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-947-7500
Provider Business Practice Location Address Fax Number:
215-947-7501
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHACHKIN
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
215-947-7500

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0073470000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 123121 . This is a "AETNA INDIVIDUAL #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 969482 . This is a "AETNA GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1578646899 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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