1265923072 NPI number — EINSTEIN PRACTICE PLAN, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265923072 NPI number — EINSTEIN PRACTICE PLAN, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EINSTEIN PRACTICE PLAN, 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:
6
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:
1265923072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E OLNEY AVE STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19120-2470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 OLD YORK RD STE 505
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:
19141-3047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-456-8242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CANDIA
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR, PROVIDER ENROLLMENT
Authorized Official Telephone Number:
215-456-4694

Provider Taxonomy Codes

  • Taxonomy code: 207RT0003X , 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: 1007706230139 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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