1881667467 NPI number — GORDON R BAILEY P.T.

Table of content: GORDON R BAILEY P.T. (NPI 1881667467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881667467 NPI number — GORDON R BAILEY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
GORDON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1881667467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 E COLUMBUS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORRY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16407-9014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-664-9346
Provider Business Mailing Address Fax Number:
814-663-0169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 E COLUMBUS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORRY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16407-9014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-664-9346
Provider Business Practice Location Address Fax Number:
814-663-0169
Provider Enumeration Date:
02/13/2006

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: 174400000X , with the licence number:  PT009652L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: PT009652L , 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: 00025292701 . This is a "LEGACY NUMBER - UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 457211 . This is a "LEGACY NUMBER - HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9390591 . This is a "LEGACY NUMBER - IND. HEAL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".