1093798282 NPI number — DARYL W LIST D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093798282 NPI number — DARYL W LIST D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIST
Provider First Name:
DARYL
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1093798282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1088
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16148-0088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-660-8505
Provider Business Mailing Address Fax Number:
706-660-9390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 EDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRANSFER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16154-1817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-646-0400
Provider Business Practice Location Address Fax Number:
724-646-0413
Provider Enumeration Date:
11/22/2005

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: 207L00000X , with the licence number:  OS003985L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000856690 0009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101208491 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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