1972520609 NPI number — ELLIOT DIAMOND

Table of content: (NPI 1972520609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972520609 NPI number — ELLIOT DIAMOND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELLIOT DIAMOND
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:
1972520609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 CHESTNUT ST.
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19106-3051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-923-2455
Provider Business Mailing Address Fax Number:
215-923-4535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 CHESTNUT ST
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19106-3051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-923-2455
Provider Business Practice Location Address Fax Number:
215-923-4535
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIAMOND
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-923-2455

Provider Taxonomy Codes

  • Taxonomy code: 213ES0000X , with the licence number:  SC002164L , 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: 000710490 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com