1255399366 NPI number — MICHAEL W MILBOURNE MD

Table of content: MICHAEL W MILBOURNE MD (NPI 1255399366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255399366 NPI number — MICHAEL W MILBOURNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILBOURNE
Provider First Name:
MICHAEL
Provider Middle Name:
W
Provider Name Prefix Text:
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:
1255399366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 HIGHGATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMBLER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19002-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-966-1546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 E WILLOW GROVE AVE
Provider Second Line Business Practice Location Address:
STE C11
Provider Business Practice Location Address City Name:
GLENSIDE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19038-7968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-966-1546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2006

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: 207R00000X , with the licence number:  MD050826 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0901X , with the licence number: MD050825L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: MD050825L , 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: 014939000 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37794MD050825L . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0745998000 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0745998000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0745998000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5511627 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 564071 . This is a "BSPA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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