1871786673 NPI number — GRACE WOMENS CLINIC PA

Table of content: (NPI 1871786673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871786673 NPI number — GRACE WOMENS CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE WOMENS CLINIC PA
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:
GRACE WOMENS CLINIC
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:
1871786673
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2280 S CHURCH ST STE 201
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27215-5397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-538-2014
Provider Business Mailing Address Fax Number:
336-538-2015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2280 S CHURCH ST STE 201
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27215-5397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-538-2014
Provider Business Practice Location Address Fax Number:
336-538-2015
Provider Enumeration Date:
08/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNOWLES-JONAS
Authorized Official First Name:
LYNDE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
336-538-2014

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  9800935 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7911368 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022135915 . This is a "D-U-N-S#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1053375535 . This is a "RENDERING PROVIDER NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2349572 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 023X3 . This is a "BCBS GROUP#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2260309A . This is a "PROVIDER PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1871786673 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".




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