1689794679 NPI number — WHITE DEER RUN, INC

Table of content: (NPI 1689794679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689794679 NPI number — WHITE DEER RUN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE DEER RUN, INC
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:
WHITE DEER RUN OF NEW CASTLE
Provider Other Organization Name Type Code:
3
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:
1689794679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 HIGHLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CASTLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16101-2418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-657-9916
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CASTLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16101-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-657-9916
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CALLAHAN
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL VICE PRESIDENT
Authorized Official Telephone Number:
800-873-2131

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  000377014 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 000377014 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 000377014 , 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: 1007567870099 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007567870012 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007567870098 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007567870062 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".