1134470602 NPI number — M J A HEALTHCARE OF THE LEHIGH VALLEY P C

Table of content: (NPI 1134470602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134470602 NPI number — M J A HEALTHCARE OF THE LEHIGH VALLEY P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M J A HEALTHCARE OF THE LEHIGH VALLEY P C
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:
1134470602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
796 SEVEN BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-7940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-872-9800
Provider Business Mailing Address Fax Number:
570-872-9888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1104 VAN BUREN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18045-2030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-438-4460
Provider Business Practice Location Address Fax Number:
610-438-4473
Provider Enumeration Date:
09/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ARTAMONOV
Authorized Official First Name:
MIKHAIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/MD
Authorized Official Telephone Number:
610-438-4460

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  MD424898 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: MD424898 , 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)





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