1104094713 NPI number — ROBERT W. CHILDS, MD, AND ASSOCIATES

Table of content: (NPI 1104094713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104094713 NPI number — ROBERT W. CHILDS, MD, AND ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT W. CHILDS, MD, AND ASSOCIATES
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:
1104094713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 E BROAD ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
HAZLETON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18201-5622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-455-9589
Provider Business Mailing Address Fax Number:
570-455-8848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 E BROAD ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-5622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-455-9589
Provider Business Practice Location Address Fax Number:
570-455-8848
Provider Enumeration Date:
02/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-455-9589

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD014506E , 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: 0005875560001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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