1457457871 NPI number — TRACY JACKSON CALVERT M.S., P.T.

Table of content: (NPI 1982364063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457457871 NPI number — TRACY JACKSON CALVERT M.S., P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALVERT
Provider First Name:
TRACY
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., P.T.
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:
1457457871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 INNOVATION DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAIRSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15717-8096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-343-4060
Provider Business Mailing Address Fax Number:
724-343-4069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 VALLEY FORGE RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PHOENIXVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19460-2658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-917-0725
Provider Business Practice Location Address Fax Number:
610-917-0573
Provider Enumeration Date:
09/15/2006

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: 225100000X , with the licence number:  PT007283L , 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: 0516599000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 234443 . This is a "HEALTH AMER/HEALTH ASSUR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: JA667629 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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