1134395965 NPI number — PROGRESSIVE PHYSICIAN ASSOC, INC.

Table of content: (NPI 1134395965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134395965 NPI number — PROGRESSIVE PHYSICIAN ASSOC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE PHYSICIAN ASSOC, INC.
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:
1134395965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETHLEHEM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18016-1156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-868-1100
Provider Business Mailing Address Fax Number:
610-868-1111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUAKERTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18951-1573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-868-1100
Provider Business Practice Location Address Fax Number:
610-868-1111
Provider Enumeration Date:
05/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DEANGELO
Authorized Official First Name:
SUSANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATION/CREDENTIALING
Authorized Official Telephone Number:
610-868-1100

Provider Taxonomy Codes

  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1303700-0023 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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