1467429365 NPI number — MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC

Table of content: (NPI 1467429365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467429365 NPI number — MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN LINE GASTROENTEROLOGY ASSOCIATES, PC
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:
1467429365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELLERSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18960-0350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-723-2333
Provider Business Mailing Address Fax Number:
215-723-9112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 CENTRAL AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
MALVERN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19355-3265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-644-6755
Provider Business Practice Location Address Fax Number:
610-647-2063
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LASKIN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
610-644-6755

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0015085480009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA1051 . This is a "RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com