1619910239 NPI number — DR. THERESA BOLAND NEIDERER OD

Table of content: DR. THERESA BOLAND NEIDERER OD (NPI 1619910239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619910239 NPI number — DR. THERESA BOLAND NEIDERER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEIDERER
Provider First Name:
THERESA
Provider Middle Name:
BOLAND
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1619910239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 TOWNSHIP LINE RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
DREXEL HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19026-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-430-2228
Provider Business Mailing Address Fax Number:
610-644-5410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 SWEDESFORD CORPORATE CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRAZER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-644-9300
Provider Business Practice Location Address Fax Number:
610-644-5410
Provider Enumeration Date:
06/13/2006

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: 152W00000X , with the licence number:  OE006787-T , 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)





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