1306849625 NPI number — DR. MARIANNE J. SUPRYS M.D.

Table of content: (NPI 1235523937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306849625 NPI number — DR. MARIANNE J. SUPRYS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPRYS
Provider First Name:
MARIANNE
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1306849625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-3444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-336-5995
Provider Business Mailing Address Fax Number:
814-333-1025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 N MERCER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINESVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16424-9232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-683-2014
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2005

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:  MD042437E , 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: 0012040880004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20047 FCN . This is a "EPSDT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: E65436 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 122811 . This is a "UNISON HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 205047 . This is a "UPMC HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012040880007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080084839 . This is a "PALMETTO GBA-RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 251754199019 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 902560 . This is a "HIGHMARK BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4235190002 . This is a "NATIONAL SUPPLIERS CLEARINGHOUSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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