1164613840 NPI number — NATHANIEL C PEARSON M.D.

Table of content: NATHANIEL C PEARSON M.D. (NPI 1164613840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164613840 NPI number — NATHANIEL C PEARSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSON
Provider First Name:
NATHANIEL
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1164613840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650782
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-709-4485
Provider Business Mailing Address Fax Number:
302-733-0854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1331 E WYOMING AVE
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:
19124-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-537-5698
Provider Business Practice Location Address Fax Number:
877-329-2370
Provider Enumeration Date:
08/07/2007

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: 207L00000X , with the licence number:  MD431811 , 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: 102040062 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00692013 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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