1063643856 NPI number — DR. JACOB WAYNE SHIPLEY M.D.

Table of content: MRS. LINDA BRADLEY (NPI 1912458464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063643856 NPI number — DR. JACOB WAYNE SHIPLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIPLEY
Provider First Name:
JACOB
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1063643856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 S PLEASANT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15501-2262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-445-3575
Provider Business Mailing Address Fax Number:
814-445-5700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 E CHURCH ST STE 2400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-443-5800
Provider Business Practice Location Address Fax Number:
814-443-5499
Provider Enumeration Date:
07/28/2009

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: 207L00000X , with the licence number:  MD450197 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 35.123054 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: MD450197 , 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: H318750 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: CI6140 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 618271100 . This is a "ACS DEPT OF LABOR WC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0015083500031 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002533543 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000873681 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 12700751 . This is a "CAQH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 710929 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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