1487655445 NPI number — DR. MALLORY LYNN EISENMAN DPM

Table of content: DR. MALLORY LYNN EISENMAN DPM (NPI 1487655445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487655445 NPI number — DR. MALLORY LYNN EISENMAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENMAN
Provider First Name:
MALLORY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1487655445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 RITTENHOUSE SQ
Provider Second Line Business Mailing Address:
SUITE C3
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19103-5767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-735-3668
Provider Business Mailing Address Fax Number:
215-735-1838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 RITTENHOUSE SQ
Provider Second Line Business Practice Location Address:
SUITE C3
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103-5767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-735-3668
Provider Business Practice Location Address Fax Number:
215-735-1838
Provider Enumeration Date:
08/02/2005

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: 213E00000X , with the licence number:  SC0021671 , 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: 0480001090 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000492696 . This is a "BLUECROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 402696 . This is a "HIGHMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010346300001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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