1215986880 NPI number — PENNSYLVANIA PAIN MANAGEMENT, INC.

Table of content: (NPI 1215986880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215986880 NPI number — PENNSYLVANIA PAIN MANAGEMENT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNSYLVANIA PAIN MANAGEMENT, 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:
1215986880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1251 S CEDAR CREST BLVD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18103-6205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-439-1662
Provider Business Mailing Address Fax Number:
610-439-8397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 S CEDAR CREST BLVD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18103-6205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-439-1662
Provider Business Practice Location Address Fax Number:
610-439-8397
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHOQUETTE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
610-439-1662

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02803100 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000768841 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1520393 . This is a "GATEWAY HEALTHPLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P3033420 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016272440006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 823259 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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