1174544498 NPI number — PENN TRAFFIC CO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174544498 NPI number — PENN TRAFFIC CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENN TRAFFIC CO
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:
6
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:
1174544498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 STATE FAIR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13209-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-461-2600
Provider Business Mailing Address Fax Number:
315-461-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 S WHITE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15825-2422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-849-7548
Provider Business Practice Location Address Fax Number:
814-849-9650
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAHONEY
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SVP/GENERAL COUNSEL
Authorized Official Telephone Number:
315-461-2347

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PP414919L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01465807 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3968558 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1007783900034 . This is a "PA PROMISE- MEDICAID" identifier . This identifiers is of the category "OTHER".




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