1013976109 NPI number — JEROME BROAD CRNA

Table of content: JEROME BROAD CRNA (NPI 1013976109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013976109 NPI number — JEROME BROAD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROAD
Provider First Name:
JEROME
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

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:
1013976109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 N DUKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17602-2250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-544-5511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 N DUKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17602-2250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-544-5511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2006

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: 367500000X , with the licence number:  RN326693L , 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: 4574637 . This is a "AETNA-NON HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50055744 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0229988000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50055744 . This is a "KEYSTONE HEALTH PLAN CENTRAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1147543 . This is a "AETNA-HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00233842 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000535767 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 106579 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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