1063474435 NPI number — GUSTAV R ELES DO

Table of content: GUSTAV R ELES DO (NPI 1063474435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063474435 NPI number — GUSTAV R ELES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELES
Provider First Name:
GUSTAV
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1063474435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
995 BEAVER GRADE RD STE B2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAOPOLIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15108-2766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-264-9500
Provider Business Mailing Address Fax Number:
412-264-8999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 BEAVER GRADE ROAD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CORAOPOLIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15108-2766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-264-9500
Provider Business Practice Location Address Fax Number:
412-264-8999
Provider Enumeration Date:
04/03/2006

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: 207RC0000X , with the licence number:  OS005112L , 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: 3810017484 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1079909 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1605U . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2195413 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0010799090027 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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