1710002936 NPI number — PMSI DIVISION OF RHEUMATOLOGY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710002936 NPI number — PMSI DIVISION OF RHEUMATOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PMSI DIVISION OF RHEUMATOLOGY
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:
6
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:
1710002936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 MEDICAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19464-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-327-4200
Provider Business Mailing Address Fax Number:
610-327-8160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1566 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
POTTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19464-3229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-945-0075
Provider Business Practice Location Address Fax Number:
484-945-0781
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ENOCHS
Authorized Official First Name:
SHANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
610-327-4200

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  OS009934L , 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: 1392933 . This is a "BLUE SHIELD ASSIGN ACCT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2082006000 . This is a "KEYSTONE HMO" identifier . This identifiers is of the category "OTHER".




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