1154767986 NPI number — DR. BRIAN EDWARD WALKOWSKI M.D.

Table of content: DR. BRIAN EDWARD WALKOWSKI M.D. (NPI 1154767986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154767986 NPI number — DR. BRIAN EDWARD WALKOWSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKOWSKI
Provider First Name:
BRIAN
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1154767986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUMFORD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02916-0697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-854-2428
Provider Business Mailing Address Fax Number:
401-868-2385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1086 FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-534-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2013

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: 208600000X , with the licence number:  MD17007 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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