1679638985 NPI number — SEWICKLEY VALLEY RHEUMATOLOGY LLC

Table of content: (NPI 1679638985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679638985 NPI number — SEWICKLEY VALLEY RHEUMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEWICKLEY VALLEY RHEUMATOLOGY LLC
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:
1679638985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1196 MERCHANT STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMBRIDGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15003-2335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-266-2447
Provider Business Mailing Address Fax Number:
724-266-2920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1196 MERCHANT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMBRIDGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15003-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-266-2447
Provider Business Practice Location Address Fax Number:
724-266-2920
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BACU
Authorized Official First Name:
GERI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
724-266-2447

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  MD049189L , 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: 1633767 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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