1417993866 NPI number — ADRIENNE PINCKNEY MPT

Table of content: ADRIENNE PINCKNEY MPT (NPI 1417993866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417993866 NPI number — ADRIENNE PINCKNEY MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PINCKNEY
Provider First Name:
ADRIENNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREEN
Provider Other First Name:
ADRIENNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417993866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4102 OGLETOWN STANTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-4169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-894-1800
Provider Business Practice Location Address Fax Number:
302-894-1811
Provider Enumeration Date:
06/22/2006

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: 225100000X , with the licence number:  J10001776 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000037748 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1751427 . This is a "PABS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5070-0034 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2116519 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62116101 . This is a "NCA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2417148000 . This is a "AMERIHEALTH IBC" identifier . This identifiers is of the category "OTHER".




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