1174596530 NPI number — INTERNAL MEDICINE SPECIALIST LLC

Table of content: (NPI 1174596530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174596530 NPI number — INTERNAL MEDICINE SPECIALIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE SPECIALIST LLC
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:
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:
1174596530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 SECOND STREET PIKE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18966-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-322-5002
Provider Business Mailing Address Fax Number:
215-322-5008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 SECOND STREET PIKE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SOUTHAMPTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18966-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-322-5002
Provider Business Practice Location Address Fax Number:
215-322-5008
Provider Enumeration Date:
02/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PURPURA
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
215-322-5002

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS009043L , 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: 034025TNR . This is a "MEDICARE PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com