1255361697 NPI number — DR. STEPHEN WACHTEL MD

Table of content: DR. STEPHEN WACHTEL MD (NPI 1255361697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255361697 NPI number — DR. STEPHEN WACHTEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WACHTEL
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1255361697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15501-0336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-444-8910
Provider Business Mailing Address Fax Number:
814-444-9782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W BERKELEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIONTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15401-5514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-430-5159
Provider Business Practice Location Address Fax Number:
724-430-3382
Provider Enumeration Date:
07/03/2006

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: 207ZP0102X , with the licence number:  MD 057323-L , 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: 0401455000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016088570002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0401455000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: WA674812 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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