1144279779 NPI number — DR. SARA L WALLACH M.D.

Table of content: DR. SARA L WALLACH M.D. (NPI 1144279779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144279779 NPI number — DR. SARA L WALLACH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACH
Provider First Name:
SARA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1144279779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 W ELM ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-4108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-567-6000
Provider Business Mailing Address Fax Number:
610-567-6955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 HAMILTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08629-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-599-5050
Provider Business Practice Location Address Fax Number:
609-599-4318
Provider Enumeration Date:
05/10/2006

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: 207R00000X , with the licence number:  25MA05698800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6731309 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".