1063879393 NPI number — MARYRUTH L. NICH

Table of content: MARYRUTH L. NICH (NPI 1063879393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063879393 NPI number — MARYRUTH L. NICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICH
Provider First Name:
MARYRUTH
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOPRESTI
Provider Other First Name:
MARYRUTH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063879393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HYGEIA DR
Provider Second Line Business Mailing Address:
CCHS PHYSICIAN CONTRACTING, SUITE 2300
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2049
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:
86 OMEGA DR
Provider Second Line Business Practice Location Address:
OMEGA PROFESSIONAL CENTER, BUILDING B-86
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-1929
Provider Business Practice Location Address Fax Number:
302-366-1075
Provider Enumeration Date:
01/18/2016

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: 163W00000X , with the licence number:  L1-0033156 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: LG-0000912 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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