1083683742 NPI number — PEDIATRIC ASSOCIATES OF PAOLI, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083683742 NPI number — PEDIATRIC ASSOCIATES OF PAOLI, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ASSOCIATES OF PAOLI, 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:
PEDIATRIC ASSOCIATES OF PAOLI
Provider Other Organization Name Type Code:
3
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:
1083683742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 INDUSTRIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
PAOLI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19301-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-647-1484
Provider Business Mailing Address Fax Number:
610-647-7068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 INDUSTRIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
PAOLI
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19301-1607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-647-1484
Provider Business Practice Location Address Fax Number:
610-647-7068
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIENZLE
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
610-647-1484

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , 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: 897325 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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