1528039591 NPI number — WEST BRANCH ORTHOPEDICS AND SPORTS MEDICINE

Table of content: (NPI 1528039591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528039591 NPI number — WEST BRANCH ORTHOPEDICS AND SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST BRANCH ORTHOPEDICS AND SPORTS MEDICINE
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:
1528039591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
699 RURAL AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17701-3246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-322-3640
Provider Business Mailing Address Fax Number:
570-322-3656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
699 RURAL AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701-3246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-322-3640
Provider Business Practice Location Address Fax Number:
570-322-3656
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAREY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
ORTHOPEDIC DOCTOR
Authorized Official Telephone Number:
570-322-3640

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , 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: 0012256040001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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