1104810860 NPI number — MARY ANN LEARY DO

Table of content: MARY ANN LEARY DO (NPI 1104810860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104810860 NPI number — MARY ANN LEARY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEARY
Provider First Name:
MARY ANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1104810860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 W ELM ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-567-6967
Provider Business Mailing Address Fax Number:
610-567-6955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 RIDGE PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLEVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19403-1411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-539-9100
Provider Business Practice Location Address Fax Number:
610-539-6570
Provider Enumeration Date:
09/08/2005

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: 207Q00000X , with the licence number:  OS008302L , 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: 0015040010005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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