1225012891 NPI number — MR. JOHN R MANZELLA JR. DO

Table of content: MR. JOHN R MANZELLA JR. DO (NPI 1225012891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225012891 NPI number — MR. JOHN R MANZELLA JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANZELLA
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
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:
1225012891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1353 STATE ROUTE 903
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JIM THORPE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18229-2734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-325-8393
Provider Business Mailing Address Fax Number:
570-325-8029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1353 STATE ROUTE 903
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JIM THORPE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18229-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-325-8393
Provider Business Practice Location Address Fax Number:
570-325-8029
Provider Enumeration Date:
12/06/2005

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: 207R00000X , with the licence number:  OS010263L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: OS010263L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0314295000 . This is a "PERSONAL BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03197301 . This is a "CAPITAL BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010054200 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5389099 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001780247 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176513 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2968846 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20031252 . This is a "AMERIHEALTH MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00600418 . This is a "PALMETTO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1753980 . This is a "FEDERAL BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 176513 . This is a "AMERIHEALTH ADMIN" identifier . This identifiers is of the category "OTHER".




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