1386057776 NPI number — JUSTINE KOSTRUB MD

Table of content: JUSTINE KOSTRUB MD (NPI 1386057776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386057776 NPI number — JUSTINE KOSTRUB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSTRUB
Provider First Name:
JUSTINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1386057776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 BLACKBURN RD., 1ST FLOOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEWICKLEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-741-0985
Provider Business Mailing Address Fax Number:
412-749-6785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 BLACKBURN RD FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEWICKLEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15143-1459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-741-0985
Provider Business Practice Location Address Fax Number:
412-749-6785
Provider Enumeration Date:
06/04/2014

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: 390200000X , with the licence number:  MT-207188 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD461424 , 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: 103147653 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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