1336170620 NPI number — LISA CONNIFF PT

Table of content: LISA CONNIFF PT (NPI 1336170620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336170620 NPI number — LISA CONNIFF PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNIFF
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TARHANICH
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336170620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 SECOND AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JESSUP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18434
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:
107 NP 502 PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18444-9266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-848-1240
Provider Business Practice Location Address Fax Number:
570-848-1243
Provider Enumeration Date:
07/05/2006

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: 225100000X , with the licence number:  PT-011722L , 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: 0239015000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 29284 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5975668 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 820367 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50060152 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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