1245403286 NPI number — THOMAS P DOUGHERTY ORAL MAXILLOFACIAL SURGERY PA

Table of content: (NPI 1245403286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245403286 NPI number — THOMAS P DOUGHERTY ORAL MAXILLOFACIAL SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS P DOUGHERTY ORAL MAXILLOFACIAL SURGERY PA
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:
1245403286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5317 LIMESTONE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-1252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-239-2500
Provider Business Mailing Address Fax Number:
302-239-0552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5317 LIMESTONE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19808-1252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-239-2500
Provider Business Practice Location Address Fax Number:
302-239-0552
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGHERTY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
P
Authorized Official Title or Position:
ORAL MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
302-239-2500

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000912501 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54490 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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