1972645893 NPI number — CORNELL ABRAXAS GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972645893 NPI number — CORNELL ABRAXAS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNELL ABRAXAS GROUP LLC
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:
6
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:
1972645893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2840 LIBERTY AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15222-4776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-566-6656
Provider Business Mailing Address Fax Number:
814-927-8560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 ABRAXAS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIENVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-566-6656
Provider Business Practice Location Address Fax Number:
814-927-8560
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SADLER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
814-566-6656

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  271010 , 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: 271010 . This is a "DDAPL LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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