1508905209 NPI number — MRS. TERESA ICHNIOWSKI P.T.

Table of content: MRS. TERESA ICHNIOWSKI P.T. (NPI 1508905209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508905209 NPI number — MRS. TERESA ICHNIOWSKI P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ICHNIOWSKI
Provider First Name:
TERESA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1508905209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10408 HUNTLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20902-3822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-649-1558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 UNIVERSITY BLVD W
Provider Second Line Business Practice Location Address:
SUITE 714
Provider Business Practice Location Address City Name:
WHEATON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20902-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-942-2520
Provider Business Practice Location Address Fax Number:
301-942-6998
Provider Enumeration Date:
02/06/2007

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: 2251G0304X , with the licence number:  14713 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 612022-01 . This is a "BC BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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