1104425768 NPI number — DANIEL CASSIDY HIS

Table of content: DANIEL CASSIDY HIS (NPI 1104425768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104425768 NPI number — DANIEL CASSIDY HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSIDY
Provider First Name:
DANIEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HIS
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:
1104425768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 MARLTON PIKE WEST
Provider Second Line Business Mailing Address:
MIRACLE-EAR CENTER
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-471-7870
Provider Business Mailing Address Fax Number:
856-665-6813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 FOXHUNT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAR
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19701-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-392-2797
Provider Business Practice Location Address Fax Number:
856-665-6813
Provider Enumeration Date:
10/23/2020

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: 237700000X , with the licence number:  O3-0010282 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: O3-0010282 . This is a "STATE OF DELAWARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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