1295074417 NPI number — W.A.B. PHYSICAL MEDICINE & REHABILITATION OF PA, PC

Table of content: (NPI 1295074417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295074417 NPI number — W.A.B. PHYSICAL MEDICINE & REHABILITATION OF PA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W.A.B. PHYSICAL MEDICINE & REHABILITATION OF PA, PC
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:
ROBERT RUNDORFF MD, PC
Provider Other Organization Name Type Code:
4
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:
1295074417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 ROSE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15905-4327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-539-0257
Provider Business Mailing Address Fax Number:
814-536-0963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 ROSE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-4327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-539-0257
Provider Business Practice Location Address Fax Number:
814-536-0963
Provider Enumeration Date:
02/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BERGIN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
814-539-0257

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1295074417 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2896336 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1028363120001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com