1487488664 NPI number — PANTHERX SPECIALTY LLC

Table of content: (NPI 1487488664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487488664 NPI number — PANTHERX SPECIALTY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PANTHERX SPECIALTY LLC
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:
1487488664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 BAYER RD BLDG 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15205-9706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-726-8479
Provider Business Mailing Address Fax Number:
855-246-3986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 MOORE LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-726-8479
Provider Business Practice Location Address Fax Number:
855-246-3986
Provider Enumeration Date:
08/29/2024

Additional Information

Authorized Official

Authorized Official Last Name:
CRAIN
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTS MANAGER
Authorized Official Telephone Number:
855-726-8479

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1487488664 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487488664 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487488664 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6718462 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487488664 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300100596 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30015069640005 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000238468 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487488664 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200566670C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102702417-0004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7101025040 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q097581 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100296778 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3147472 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0079597 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177060 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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