1225212137 NPI number — US VASCULAR ACCESS CENTER OF PHILADELPHIA, LLC

Table of content: (NPI 1225212137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225212137 NPI number — US VASCULAR ACCESS CENTER OF PHILADELPHIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
US VASCULAR ACCESS CENTER OF PHILADELPHIA, LLC
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:
1225212137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4220 MARKET ST
Provider Second Line Business Mailing Address:
SECOND FLOOR
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-3007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-386-4959
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 MARKET ST
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-3007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-386-4959
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
EDITH
Authorized Official Middle Name:
Authorized Official Title or Position:
SR.MGR. REGULATORY/REIMBURSEMENT
Authorized Official Telephone Number:
407-661-5766

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  20461501 , 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: 20461501 . This is a "STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".