1003692617 NPI number — AEG PENNSYLVANIA PROFESSIONAL, INC

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 1003692617 NPI number — AEG PENNSYLVANIA PROFESSIONAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AEG PENNSYLVANIA PROFESSIONAL, INC
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:
1003692617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 E 4TH ST STE 440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-6206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-462-9818
Provider Business Mailing Address Fax Number:
314-741-4947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4156 WILLIAM PENN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROEVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15146-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-372-8188
Provider Business Practice Location Address Fax Number:
314-741-4947
Provider Enumeration Date:
09/08/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ALLISON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. DIRECTOR RCM/MVC
Authorized Official Telephone Number:
618-462-9818

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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