1356570329 NPI number — ALIA ANTONUCCI-ALTER EDELEN DPT

Table of content: ALIA ANTONUCCI-ALTER EDELEN DPT (NPI 1356570329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356570329 NPI number — ALIA ANTONUCCI-ALTER EDELEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDELEN
Provider First Name:
ALIA
Provider Middle Name:
ANTONUCCI-ALTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1356570329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2122 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-550-0168
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5838 SIX FORKS RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-3893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-782-5954
Provider Business Practice Location Address Fax Number:
919-890-5304
Provider Enumeration Date:
07/10/2009

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: 225100000X , with the licence number:  P12202 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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