1235369059 NPI number — LABORATORY OF PODIATRIC PATHOLOGY, P.C.

Table of content: (NPI 1235369059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235369059 NPI number — LABORATORY OF PODIATRIC PATHOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LABORATORY OF PODIATRIC PATHOLOGY, P.C.
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:
1235369059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 ARCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-2413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-238-9831
Provider Business Mailing Address Fax Number:
215-238-1873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 ARCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-2413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-238-9831
Provider Business Practice Location Address Fax Number:
215-238-1873
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LEMONT
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PODIATRIST/LABORATORY DIRECTOR
Authorized Official Telephone Number:
215-238-9831

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  021451 , 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: 021451 . This is a "STATE PERMIT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: LA300113 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1192666101 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39D0657757 . This is a "CLIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: LE137290 . This is a "PODIATRY LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 291U00000X . This is a "PROVIDER TAXONOMIES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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