1487004503 NPI number — REDICLINIC OF PA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487004503 NPI number — REDICLINIC OF PA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDICLINIC OF PA, LLC
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:
1487004503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 GREENWAY PLZ
Provider Second Line Business Mailing Address:
SUITE 2950
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77046-0905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-335-1731
Provider Business Mailing Address Fax Number:
713-358-4881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 N 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18101-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-335-1731
Provider Business Practice Location Address Fax Number:
713-358-4881
Provider Enumeration Date:
06/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PETTIGREW
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DIRECTOR, PAYER RELATIONS
Authorized Official Telephone Number:
713-335-1731

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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