1134365620 NPI number — PENNSYLVANIA INTERNAL MEDICINE & GERIATRICS PC

Table of content: (NPI 1134365620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134365620 NPI number — PENNSYLVANIA INTERNAL MEDICINE & GERIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNSYLVANIA INTERNAL MEDICINE & GERIATRICS 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:
1134365620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9501 HILSPACH 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:
19115-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-637-0102
Provider Business Mailing Address Fax Number:
215-281-0464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9503 STATE RD
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:
19114-3034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-637-0102
Provider Business Practice Location Address Fax Number:
215-281-0464
Provider Enumeration Date:
01/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BERGMAN
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
215-637-0102

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X , with the licence number:  MD012582E , 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: 000592556 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 835253 . This is a "AETNA INSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0053907001 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 110026458 . This is a "PALMETTO GBA MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 129328701 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 035806 . This is a "HIGHMARK MEDICARE SERVICES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 19361 . This is a "BRAVO HEALTHCRE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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