1336684133 NPI number — SAMANTHA JO ANGELO PA

Table of content: SAMANTHA JO ANGELO PA (NPI 1336684133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336684133 NPI number — SAMANTHA JO ANGELO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANGELO
Provider First Name:
SAMANTHA
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRONLUND
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336684133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
810 CLAIRTON BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15236-4519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-466-5004
Provider Business Mailing Address Fax Number:
412-466-7137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 CLAIRTON BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15236-4519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-466-5004
Provider Business Practice Location Address Fax Number:
412-466-7137
Provider Enumeration Date:
01/03/2017

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: 363A00000X , with the licence number:  MA058717 , 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)