1023168697 NPI number — SHANNON CLIFFORD PT

Table of content: SHANNON CLIFFORD PT (NPI 1023168697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023168697 NPI number — SHANNON CLIFFORD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLIFFORD
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1023168697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 NEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08225-1669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 NEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08225-1669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-645-2514
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2007

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:  PT015941 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 40QA01382700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1060416 . This is a "WORKERS COMP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1418430 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019168370003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".