1063706315 NPI number — MATT SHOLLENBERGER, PHD PC

Table of content: (NPI 1063706315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063706315 NPI number — MATT SHOLLENBERGER, PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATT SHOLLENBERGER, PHD PC
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:
1063706315
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 N PARK RD STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYOMISSING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19610-1341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-459-6423
Provider Business Mailing Address Fax Number:
484-388-4359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 NORTH PARK ROAD SUITE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYOMISSING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-459-6423
Provider Business Practice Location Address Fax Number:
484-388-4359
Provider Enumeration Date:
06/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHOLLENBERGER
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/COUNSELOR
Authorized Official Telephone Number:
484-459-6423

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  PC002868 , 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: 2750535 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 592454000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2319238000 . This is a "IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2290709 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50102905 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7784522 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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