1528248655 NPI number — MID ATLANTIC SURGICAL LLC

Table of content: (NPI 1528248655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528248655 NPI number — MID ATLANTIC SURGICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID ATLANTIC SURGICAL 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:
1528248655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19803-8157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-652-6050
Provider Business Mailing Address Fax Number:
302-652-6053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 W BALTIMORE PIKE
Provider Second Line Business Practice Location Address:
MOB SUITE 201
Provider Business Practice Location Address City Name:
WEST GROVE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19390-9459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-652-6050
Provider Business Practice Location Address Fax Number:
302-652-6053
Provider Enumeration Date:
11/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TRUSCELLO
Authorized Official First Name:
NORA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
302-652-6050

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007648708 . This is a "AETNA PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1012770780002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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