1255400081 NPI number — BODY REBUILDERS, P.C.

Table of content: (NPI 1255400081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255400081 NPI number — BODY REBUILDERS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BODY REBUILDERS, 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:
1255400081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 E CITY AVE
Provider Second Line Business Mailing Address:
STE 250
Provider Business Mailing Address City Name:
BALA CYNWYD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19004-1704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-668-4055
Provider Business Mailing Address Fax Number:
610-668-4250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 CITY AVENUE
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-668-4055
Provider Business Practice Location Address Fax Number:
610-668-4250
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALTMAN LESHER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
U.
Authorized Official Title or Position:
VICE PRESIDENT/PT
Authorized Official Telephone Number:
610-668-4055

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 501213 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0215514000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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