1497316996 NPI number — PRACTITIONER LLC

Table of content: (NPI 1497316996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497316996 NPI number — PRACTITIONER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTITIONER 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:
NP MEDICINE
Provider Other Organization Name Type Code:
3
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:
1497316996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 BUSTLETON PIKE STE 16A3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEASTERVILLE TREVOSE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19053-4118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-223-7738
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 BUSTLETON PIKE STE 16A3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEASTERVILLE TREVOSE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19053-4118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-223-7738
Provider Business Practice Location Address Fax Number:
877-416-0367
Provider Enumeration Date:
06/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
KAVTARADZE
Authorized Official First Name:
NINO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRIMARY CARE PROVIDER, SHAREHOLDER
Authorized Official Telephone Number:
267-223-7738

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1037033750001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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