1932112174 NPI number — AVIS BEHAVIORAL HEALTH

Table of content: ROBERT J FLECK JR. M.D. (NPI 1720094147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932112174 NPI number — AVIS BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVIS BEHAVIORAL HEALTH
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:
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:
1932112174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 WEST CENTRAL AVE.
Provider Second Line Business Mailing Address:
PO BOX 1070
Provider Business Mailing Address City Name:
AVIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17721-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-753-3620
Provider Business Mailing Address Fax Number:
570-753-3620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 WEST CENTRAL AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17721-1070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-753-3620
Provider Business Practice Location Address Fax Number:
570-753-3620
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DERSHEM
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT OWNER PSYCHOTHERAPIST
Authorized Official Telephone Number:
570-753-3620

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW008439L , 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: 817938 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1617662 . This is a "HIGHMARK BC/BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2117726 . This is a "CIGNA/GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 474483 . This is a "VALUE OPTIONS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 083604 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com