1205491149 NPI number — TREXLER PARK GYNECOLOGY

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 1205491149 NPI number — TREXLER PARK GYNECOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREXLER PARK GYNECOLOGY
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:
1205491149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 N CEDAR CREST BLVD STE 110B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18104-2351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-973-1410
Provider Business Mailing Address Fax Number:
610-973-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 COLLEGE HEIGHTS BLVD STE 2200B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18104-4812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-440-3403
Provider Business Practice Location Address Fax Number:
610-433-2395
Provider Enumeration Date:
05/07/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VIECHNICKI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
610-440-3403

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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