1447256904 NPI number — PRESTIGE MANAGEMENT SERVICE CORP

Table of content: (NPI 1447256904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447256904 NPI number — PRESTIGE MANAGEMENT SERVICE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESTIGE MANAGEMENT SERVICE CORP
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:
6
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:
1447256904
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:
PO BOX 269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15074-0269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-774-6990
Provider Business Mailing Address Fax Number:
724-774-6969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
638 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15074-1643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-774-6990
Provider Business Practice Location Address Fax Number:
724-774-6969
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BAUGHMANE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-774-6990

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  02172 , 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: 1008874 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012293180002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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