1366591596 NPI number — EASY STRIDE PAIN & INJURY CENTER, PC

Table of content: (NPI 1366591596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366591596 NPI number — EASY STRIDE PAIN & INJURY CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASY STRIDE PAIN & INJURY CENTER, 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:
1366591596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4014 LANCASTER AVE # A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-1712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-222-2225
Provider Business Mailing Address Fax Number:
215-222-3070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4014 LANCASTER AVE # A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-222-2225
Provider Business Practice Location Address Fax Number:
215-222-3070
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BANCROFT
Authorized Official First Name:
J
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
215-222-2225

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  SC-001795-L , 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: 1073543559 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0500527 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1049959 . This is a "KEYSTONE MERCY - EASY STR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 31700 . This is a "KEYSTONE MERCY INDIVIDUAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0050052704 . This is a "AMERICHOICE OF PA INDIVID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com