1053630368 NPI number — TPS IV OF PA., LLC

Table of content: (NPI 1053630368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053630368 NPI number — TPS IV OF PA., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TPS IV OF PA., 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:
1053630368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 827965
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-7965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-396-0940
Provider Business Mailing Address Fax Number:
856-396-0127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 LINCOLN DR. WEST STE 301
Provider Second Line Business Practice Location Address:
4 GREENTREE CENTER
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053-3408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-396-0940
Provider Business Practice Location Address Fax Number:
856-396-0127
Provider Enumeration Date:
05/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP REGIONAL OPERATIONS, TENET
Authorized Official Telephone Number:
469-893-6193

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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