1437177979 NPI number — JOEL S ENRIQUEZ MD

Table of content: JOEL S ENRIQUEZ MD (NPI 1437177979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437177979 NPI number — JOEL S ENRIQUEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENRIQUEZ
Provider First Name:
JOEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1437177979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 GLOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CASTLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16105-1224
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:
5500 MARKET ST STE 119
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-824-4096
Provider Business Practice Location Address Fax Number:
724-269-9476
Provider Enumeration Date:
07/17/2006

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: 174400000X , with the licence number:  MD032828E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: MD032828E , 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: 0010515970014 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2478251 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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