1851393268 NPI number — MBEMBO BONGUTU MD

Table of content: MBEMBO BONGUTU MD (NPI 1851393268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851393268 NPI number — MBEMBO BONGUTU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONGUTU
Provider First Name:
MBEMBO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1851393268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16550-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-877-4922
Provider Business Mailing Address Fax Number:
814-877-3622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16550-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-877-4922
Provider Business Practice Location Address Fax Number:
814-877-3622
Provider Enumeration Date:
08/15/2005

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: 207Q00000X , with the licence number:  MD062832L , 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: P001411 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 00026887601 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01983279 . This is a "NY MEDICAL ASSISTANCE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 75913 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 080163990 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 323780 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1645032 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2228324 . This is a "OHIO MEDICAL ASSISTANCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0016842690006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7441061 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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