1073835039 NPI number — NORTHEAST MEDICAL SALES

Table of content: (NPI 1073835039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073835039 NPI number — NORTHEAST MEDICAL SALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MEDICAL SALES
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:
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:
1073835039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 JOHNSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18844-8019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-965-0964
Provider Business Mailing Address Fax Number:
570-965-0964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2354 OLD POST RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
COPLAY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18037-2461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-262-3331
Provider Business Practice Location Address Fax Number:
610-262-3399
Provider Enumeration Date:
02/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DANNECKER
Authorized Official First Name:
TAMMI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SENIOR PARTNER
Authorized Official Telephone Number:
570-965-0964

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X , with the licence number:  6000004877 , registered in the state of PA ; 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)

  • Identifier: 39HA79 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016073300002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1517547 . This is a "GATEWAY/GATEWAY MEDICARE ASSURED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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