1164507927 NPI number — FRANK L. CONLY

Table of content: (NPI 1164507927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164507927 NPI number — FRANK L. CONLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRANK L. CONLY
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:
FAMILY PRACTICE OF RENOVO
Provider Other Organization Name Type Code:
3
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:
1164507927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 HURON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENOVO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17764-1191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-923-2700
Provider Business Mailing Address Fax Number:
570-923-0824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 HURON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENOVO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17764-1191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-923-2700
Provider Business Practice Location Address Fax Number:
570-923-0824
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CONLY
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-923-2700

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002954 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000946170004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 188455 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DD5539 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1204 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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