1447828058 NPI number — SAMUEL MICHAEL LOFFREDO PA-C

Table of content: SAMUEL MICHAEL LOFFREDO PA-C (NPI 1447828058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447828058 NPI number — SAMUEL MICHAEL LOFFREDO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOFFREDO
Provider First Name:
SAMUEL
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1447828058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 MACK BLVD FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18103-5622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-629-2282
Provider Business Mailing Address Fax Number:
570-476-3475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
447 PLAZA COURT
Provider Second Line Business Practice Location Address:
BUILDING 500
Provider Business Practice Location Address City Name:
EAST STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18301-1830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-426-2301
Provider Business Practice Location Address Fax Number:
570-476-2306
Provider Enumeration Date:
06/11/2021

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: 363AS0400X , with the licence number:  MA062499 , 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: MA062499 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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