1366570947 NPI number — BETH M PACOCHA AUER PT, MPT

Table of content: BETH M PACOCHA AUER PT, MPT (NPI 1366570947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366570947 NPI number — BETH M PACOCHA AUER PT, MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACOCHA AUER
Provider First Name:
BETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, MPT
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:
1366570947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1377 MOTOR PKWY
Provider Second Line Business Mailing Address:
STE 307
Provider Business Mailing Address City Name:
ISLANDIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11749-5258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-580-5200
Provider Business Mailing Address Fax Number:
631-580-5222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 LINCOLN HWY
Provider Second Line Business Practice Location Address:
SUITE 28
Provider Business Practice Location Address City Name:
FAIRVIEW HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62208-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-622-5180
Provider Business Practice Location Address Fax Number:
618-622-5169
Provider Enumeration Date:
03/02/2007

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:  2006033635 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070014335 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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