1194937623 NPI number — MERRIAM PARK PSYCHOLOGICAL SERVICES, PA

Table of content: (NPI 1194937623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194937623 NPI number — MERRIAM PARK PSYCHOLOGICAL SERVICES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRIAM PARK PSYCHOLOGICAL SERVICES, PA
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:
1194937623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1678 SELBY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-647-5722
Provider Business Mailing Address Fax Number:
651-647-5723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1678 SELBY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-647-5722
Provider Business Practice Location Address Fax Number:
651-647-5723
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAULE-KRONMILLER
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
651-647-5722

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 826823100 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01H82MA . This is a "BCBS GROUP PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01H83MA . This is a "BCBS IND. PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 107019 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6126079 . This is a "UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1016735 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6126079 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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