1336175595 NPI number — HORIZON MEDICAL CORPORATION PC

Table of content: (NPI 1336175595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336175595 NPI number — HORIZON MEDICAL CORPORATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HORIZON MEDICAL CORPORATION 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:
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:
1336175595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 KELLY ST STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCHBALD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18403-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-876-1735
Provider Business Mailing Address Fax Number:
570-876-1813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1721 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18508-1995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-961-9947
Provider Business Practice Location Address Fax Number:
570-341-5043
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
570-876-1735

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40158 . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017929090002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 809779 . This is a "FIRST PRIORITY HEALTH GRO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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