1649311325 NPI number — NANTICOKE GASTROENTEROLOGY, P.A.

Table of content: KYLA GOODMAN (NPI 1518570423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649311325 NPI number — NANTICOKE GASTROENTEROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NANTICOKE GASTROENTEROLOGY, P.A.
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:
1649311325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 MIDDLEFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEAFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19973-3604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-629-2229
Provider Business Mailing Address Fax Number:
302-629-2285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 MIDDLEFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-629-2229
Provider Business Practice Location Address Fax Number:
302-629-2285
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACKLER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
302-629-2229

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  C10004336 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1939 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0000825302 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 421862 . This is a "OPT CHOICE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0916029 00 . This is a "MARYLAND MEDICAID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 100010338 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2714 . This is a "CAREFIRST" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 421862 . This is a "MDIPA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 505182 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: T266 . This is a "BLUECROSS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 085567809 . This is a "CHAMPUS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: PAL58270210001 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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