1578607305 NPI number — CARRIAGE HOUSE MEDICAL GROUP, 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 1578607305 NPI number — CARRIAGE HOUSE MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARRIAGE HOUSE MEDICAL GROUP, 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:
1578607305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1811 BETHLEHEM PIKE STE B211
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOURTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19031-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-419-8189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 BETHLEHEM PIKE STE B211
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOURTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19031-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-419-8189
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OKOLO
Authorized Official First Name:
EMMANUEL
Authorized Official Middle Name:
CHUKWUDI
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
267-419-8189

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM2500X , with the licence number: MD426910 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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