1609814078 NPI number — BROCA INPATIENT SERVICES

Table of content: (NPI 1609814078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609814078 NPI number — BROCA INPATIENT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROCA INPATIENT SERVICES
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:
1609814078
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:
PO BOX 42971
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19101-2971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6019 WALNUT GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-226-3190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BYRNE
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
214-712-2000

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3735123 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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