1942262019 NPI number — PERSILA V. MERTZ M.D.

Table of content: (NPI 1518417773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942262019 NPI number — PERSILA V. MERTZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERTZ
Provider First Name:
PERSILA
Provider Middle Name:
V.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1942262019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EPHRATA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17522-2710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-733-3600
Provider Business Mailing Address Fax Number:
717-721-3038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRATA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17522-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-733-3600
Provider Business Practice Location Address Fax Number:
717-721-3038
Provider Enumeration Date:
04/04/2006

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: 207W00000X , with the licence number:  MD043167E , 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: 110758 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5984190001 . This is a "DMEPOS PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 110758 . This is a "LEGACY NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 093980 . This is a "MEDICARE PROVIDER #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1093934655 . This is a "GROUP NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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