1093732455 NPI number — MR. JOSE ANTHONY GONZALO BSPH

Table of content: MR. JOSE ANTHONY GONZALO BSPH (NPI 1093732455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093732455 NPI number — MR. JOSE ANTHONY GONZALO BSPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALO
Provider First Name:
JOSE
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BSPH
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:
1093732455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 POPLAR DR
Provider Second Line Business Mailing Address:
SHADY ACRES
Provider Business Mailing Address City Name:
KULPMONT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17834-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-373-1035
Provider Business Mailing Address Fax Number:
570-373-1035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 S OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CARMEL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17851-2164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-339-5900
Provider Business Practice Location Address Fax Number:
570-339-5900
Provider Enumeration Date:
07/15/2006

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: 183500000X , with the licence number:  RP-026335L , 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)





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