1558446468 NPI number — BLOOMSBURG UNIVERSITY SPEECH & HEARING CLINIC

Table of content: (NPI 1558446468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558446468 NPI number — BLOOMSBURG UNIVERSITY SPEECH & HEARING CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMSBURG UNIVERSITY SPEECH & HEARING CLINIC
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:
1558446468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E. 2ND STREET
Provider Second Line Business Mailing Address:
CENTENNIAL HALL
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-389-5380
Provider Business Mailing Address Fax Number:
570-389-5022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 E 2ND ST
Provider Second Line Business Practice Location Address:
CENTENNIAL HALL
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-389-5380
Provider Business Practice Location Address Fax Number:
570-389-5022
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANGELO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR OF CLINICAL SERVICES
Authorized Official Telephone Number:
570-389-5380

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: D00617 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231HA2500X , with the licence number: D00617 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231HA2400X , with the licence number: D00617 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50218 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50009520 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019428910003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0019428910002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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