1588761639 NPI number — DAVID MICHAEL RAEZER MD

Table of content: DAVID MICHAEL RAEZER MD (NPI 1588761639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588761639 NPI number — DAVID MICHAEL RAEZER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAEZER
Provider First Name:
DAVID
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
INC
Provider Other First Name:
USURG
Provider Other Middle Name:
ASSOCIATES
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1588761639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1999 SPROUL RD
Provider Second Line Business Mailing Address:
SUITES 12 AND 16
Provider Business Mailing Address City Name:
BROOMALL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19008-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-534-6100
Provider Business Mailing Address Fax Number:
610-534-6104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1999 SPROUL RD
Provider Second Line Business Practice Location Address:
SUITES 12 AND 16
Provider Business Practice Location Address City Name:
BROOMALL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19008-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-534-6100
Provider Business Practice Location Address Fax Number:
610-534-6104
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  MD030565L , 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: 0031117000 . This is a "PERSONAL CHOICE ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0031117000 . This is a "AMERIHEALTH ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 146871 . This is a "BLUE SHIELD PROVIDER #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P0034748 . This is a "TRICARE PROVIDER ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00252734 . This is a "RAILROAD MEDICARE ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 025027 . This is a "BLAIR MILL ADMINISTRATORS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 12459 . This is a "ELDER HEALTH ID#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 36158333 . This is a "MULTIPLAN ID#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CL6874 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0007379020002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007380240001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0031117000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0073802406 . This is a "AMERICHOICE ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1202110002 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4088087 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DES178 . This is a "OXFORD HEALTH PLAN ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2327902 . This is a "NJ MEDICAID PROVIDER #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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