1184681389 NPI number — BRIAN M KLUCINEC MSPT

Table of content: BRIAN M KLUCINEC MSPT (NPI 1184681389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184681389 NPI number — BRIAN M KLUCINEC MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLUCINEC
Provider First Name:
BRIAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1184681389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 W ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMYRA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17078-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 NORTHEAST DR
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
HERSHEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17033-2755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-533-0215
Provider Business Practice Location Address Fax Number:
717-533-0218
Provider Enumeration Date:
05/01/2006

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: 225100000X , with the licence number:  PT012466L , 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: 50048730 . This is a "CAPITAL BC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 991848 . This is a "PA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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