1447340377 NPI number — STEPHEN E MOCK PH.D.

Table of content: STEPHEN E MOCK PH.D. (NPI 1447340377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447340377 NPI number — STEPHEN E MOCK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOCK
Provider First Name:
STEPHEN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1447340377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 406153
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-6153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-344-4327
Provider Business Mailing Address Fax Number:
570-344-7822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 ADAMS AVE
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18510-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-344-4327
Provider Business Practice Location Address Fax Number:
570-344-7822
Provider Enumeration Date:
10/13/2006

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: 231H00000X , with the licence number:  AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231HA2400X , with the licence number: AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231HA2500X , with the licence number: AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332S00000X , with the licence number: AT000199L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0012749680001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 282868 . This is a "BLUE SHIELD PROVIDER ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: AT000199L . This is a "LICENSE NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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