1548259617 NPI number — SAMUEL T DETWILER D.O.

Table of content: SAMUEL T DETWILER D.O. (NPI 1548259617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548259617 NPI number — SAMUEL T DETWILER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETWILER
Provider First Name:
SAMUEL
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1548259617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUTLER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16003-1549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-284-4084
Provider Business Mailing Address Fax Number:
724-284-4144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 MEDICAL CENTER RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICORA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16025-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-995-0123
Provider Business Practice Location Address Fax Number:
724-445-7446
Provider Enumeration Date:
10/20/2005

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: 207Q00000X , with the licence number:  34-00-7985 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: OS016525 , 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: 753111223027 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000285856 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2393299 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000285856 . This is a "UNICARE-LIFE AND HEALTH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P006463 . This is a "GATEWAY HEALTH PLAN OF OH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4489898 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: J07985 . This is a "SUMMACARE HEALTH PLAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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