1093856056 NPI number — ASTRAL PHYSICIANS PC

Table of content: (NPI 1093856056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093856056 NPI number — ASTRAL PHYSICIANS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASTRAL PHYSICIANS 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:
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:
1093856056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1251 N HOWARD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19122-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-216-4937
Provider Business Mailing Address Fax Number:
215-447-5169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 N HOWARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19122-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-216-4937
Provider Business Practice Location Address Fax Number:
215-447-5169
Provider Enumeration Date:
02/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALKENSTEIN
Authorized Official First Name:
NOI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-216-4937

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS007932L , 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: 5542028 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 025393WCN . This is a "MEDICARE GROUP MEMBER PRO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 385035 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 10938310 . This is a "CAQH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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