1962682997 NPI number — BLAIR EMERGENCY PHYSICIANS

Table of content: (NPI 1962682997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962682997 NPI number — BLAIR EMERGENCY PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAIR EMERGENCY PHYSICIANS
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:
1962682997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-7878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-732-1066
Provider Business Mailing Address Fax Number:
630-941-4333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERU
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46970-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-473-6621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STONE
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED SIGNER
Authorized Official Telephone Number:
800-355-0808

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200333950A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000327623 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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