1033144217 NPI number — WYOMISSING SURGICAL CLINIC, LTD.

Table of content: (NPI 1033144217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033144217 NPI number — WYOMISSING SURGICAL CLINIC, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMISSING SURGICAL CLINIC, LTD.
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:
SPRING RIDGE SURGICAL SPECIALISTS
Provider Other Organization Name Type Code:
3
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:
1033144217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2758 CENTURY BLVD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WYOMISSING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19610-3345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-375-0500
Provider Business Mailing Address Fax Number:
610-373-0375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2758 CENTURY BLVD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WYOMISSING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19610-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-375-0500
Provider Business Practice Location Address Fax Number:
610-373-0375
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-375-0500

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD042962L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: MD058074L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: OS009265L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: MD042962L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02325900 . This is a "KEYSTONE HEALTH PLAN CENT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02325900 . This is a "KEYSTONE SR BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02325900 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0551015 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 06562410001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2140998000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: WY1455297 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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