1275670655 NPI number — DR. MICHAEL E SRULEVICH DO

Table of content: DR. MICHAEL E SRULEVICH DO (NPI 1275670655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275670655 NPI number — DR. MICHAEL E SRULEVICH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SRULEVICH
Provider First Name:
MICHAEL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1275670655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 JUNIPER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAVERTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19083-5410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-853-5685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1553 CHESTER PIKE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CRUM LYNNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19022-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-499-7180
Provider Business Practice Location Address Fax Number:
610-499-7190
Provider Enumeration Date:
02/01/2007

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: 207QG0300X , with the licence number:  OS012617 , 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: 1019420800003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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