1477612364 NPI number — JESSUP HOSE CO 2

Table of content: (NPI 1477612364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477612364 NPI number — JESSUP HOSE CO 2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSUP HOSE CO 2
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:
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:
1477612364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1846
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAVERTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18708-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-714-3694
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 HILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JESSUP
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18434-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-498-1141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARAMELLI
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
570-489-1141

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  05117 , 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: 800356 . This is a "FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0011760450001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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