1235226671 NPI number — GRETCHEN BREWER OD

Table of content: GRETCHEN BREWER OD (NPI 1235226671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235226671 NPI number — GRETCHEN BREWER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
GRETCHEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHNEIDER
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
BREWER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235226671
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:
2329 COTTMAN AVE
Provider Second Line Business Mailing Address:
ROOSEVELT MALL
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-332-7228
Provider Business Mailing Address Fax Number:
215-332-9337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2329 COTTMAN AVE
Provider Second Line Business Practice Location Address:
ROSSEVELT MALL
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-332-7228
Provider Business Practice Location Address Fax Number:
215-332-9337
Provider Enumeration Date:
10/06/2006

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: 152W00000X , with the licence number:  OEG000944 , 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: 2037984000 . This is a "KEYSTONE HEALTHPLAN EAST" identifier , issued by the state of ( PW ) . This identifiers is of the category "OTHER".
  • Identifier: BR1345378 . This is a "BCBS PA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01975373 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1345378 . This is a "PERSONAL CHOICE BLUE CHOI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7377317 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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