1609003656 NPI number — AUTUMN REJOICE BRIDGER D.O.

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 1609003656 NPI number — AUTUMN REJOICE BRIDGER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIDGER
Provider First Name:
AUTUMN
Provider Middle Name:
REJOICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUBBARD
Provider Other First Name:
AUTUMN
Provider Other Middle Name:
REJOICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609003656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1034 GROVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-2945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-373-2156
Provider Business Mailing Address Fax Number:
814-373-2159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 POPLAR ST
Provider Second Line Business Practice Location Address:
209
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-373-2156
Provider Business Practice Location Address Fax Number:
814-373-2159
Provider Enumeration Date:
06/17/2009

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: OS016885 , 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: 102944294 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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