1487645917 NPI number — NORTHSHORE CLINICAL ASSOCIATES, LLC

Table of content: DR. SAMER ABU SALEM MD (NPI 1366272189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487645917 NPI number — NORTHSHORE CLINICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSHORE CLINICAL ASSOCIATES, 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:
1487645917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 E 2ND ST
Provider Second Line Business Mailing Address:
THIRD FLOOR
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16507-1537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-452-8300
Provider Business Mailing Address Fax Number:
814-452-8308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E 2ND ST
Provider Second Line Business Practice Location Address:
THIRD FLOOR
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16507-1537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-452-8300
Provider Business Practice Location Address Fax Number:
814-452-8308
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SEREMET
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING AND CREDENTIALING SPECIALIS
Authorized Official Telephone Number:
814-452-8248

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  MD030792E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018455840004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C0988 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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