1174513675 NPI number — MARK WALSH DO

Table of content: MARK WALSH DO (NPI 1174513675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174513675 NPI number — MARK WALSH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1174513675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1623 MORGANTOWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
READING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19607-9455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
226-228-0476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1623 MORGANTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
READING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19607-9455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
272-228-0476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2005

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: 208100000X , with the licence number:  OS007757L , 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: 1775120 . This is a "BLUE CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 819322 . This is a "BLUE CARE HMO (FPH)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4407486 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00292337 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 95285-1067 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50076569 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001540071 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001540071-0005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20041481 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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