1649430638 NPI number — SAMUEL MARSICO PT

Table of content: SAMUEL MARSICO PT (NPI 1649430638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649430638 NPI number — SAMUEL MARSICO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSICO
Provider First Name:
SAMUEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1649430638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
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:
2022 E OLD LINCOLN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANGHORNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19047-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-891-5150
Provider Business Practice Location Address Fax Number:
215-891-1410
Provider Enumeration Date:
06/12/2008

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: 225100000X , with the licence number:  J10002368 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT019681 , 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: 94292301 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1649430638 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3535006000 . This is a "IBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5070-0107 . This is a "GHMSI" identifier . This identifiers is of the category "OTHER".