1104878412 NPI number — NORTHEASTERN REHABILITATION ASSOCIATES, PC

Table of content: (NPI 1104878412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104878412 NPI number — NORTHEASTERN REHABILITATION ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEASTERN REHABILITATION ASSOCIATES, 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:
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:
1104878412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MORGAN HWY
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18508-2641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-344-3788
Provider Business Mailing Address Fax Number:
570-969-9280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MORGAN HWY
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18508-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-344-3788
Provider Business Practice Location Address Fax Number:
570-969-9280
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONAHAN-GATTO
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
570-344-3788

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 68718 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 68719 . This is a "THREE RIVERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1067 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 534357 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001252657-0006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20022351 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CF8495 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0474468000 . This is a "KEYSTONE EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 643767 . This is a "BLUE CARE/HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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