1205056348 NPI number — ERICA DEBRA BOODOO CHPT

Table of content: ERICA DEBRA BOODOO CHPT (NPI 1205056348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205056348 NPI number — ERICA DEBRA BOODOO CHPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOODOO
Provider First Name:
ERICA
Provider Middle Name:
DEBRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHPT
Provider Gender Code:
F

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:
1205056348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1441 BONSAL STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-846-2111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 HICKORY ROAD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
PLYMOUTH MEETING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-879-4471
Provider Business Practice Location Address Fax Number:
610-834-7525
Provider Enumeration Date:
04/30/2007

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: 183700000X , with the licence number:  380100106111057 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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