1053474122 NPI number — LAWRENCE COUNTY ANESTHESIA ASSOC PC

Table of content: (NPI 1053474122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053474122 NPI number — LAWRENCE COUNTY ANESTHESIA ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE COUNTY ANESTHESIA ASSOC PC
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:
THE NOUR GROUP FOR PAIN MEDICINE
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:
1053474122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
171 OMNI ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOMBELL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16123-2109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-752-5230
Provider Business Mailing Address Fax Number:
724-431-0611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 TECHNOLOGY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUTLER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16001-1785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-431-0609
Provider Business Practice Location Address Fax Number:
724-431-0611
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOUR
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
724-431-0609

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD051358L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: MD051352L , 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: 354726 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0014803580005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN8900 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000079135 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1047501 . This is a "AETNA HMO MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1503378 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 82851 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 251748 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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