1306822408 NPI number — DR. ELLEN NMN MACE DO

Table of content: DR. ELLEN NMN MACE DO (NPI 1306822408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306822408 NPI number — DR. ELLEN NMN MACE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACE
Provider First Name:
ELLEN
Provider Middle Name:
NMN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEIBSON
Provider Other First Name:
ELLEN
Provider Other Middle Name:
MACE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306822408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 700
Provider Second Line Business Mailing Address:
FCI SCHUYLKILL - HEALTH SERVICES
Provider Business Mailing Address City Name:
MINERSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17954-0700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-544-7100
Provider Business Mailing Address Fax Number:
570-544-7224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INTERSTATE 81 & 901 W
Provider Second Line Business Practice Location Address:
FCI SCHUYLKILL - HEALTH SERVICES
Provider Business Practice Location Address City Name:
MINERSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17954-0700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-544-7100
Provider Business Practice Location Address Fax Number:
570-544-7224
Provider Enumeration Date:
12/20/2005

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: 207Q00000X , with the licence number:  1904 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000582000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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