1568646628 NPI number — DR. MANSOOR MADANI DMD

Table of content: DR. MANSOOR MADANI DMD (NPI 1568646628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568646628 NPI number — DR. MANSOOR MADANI DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADANI
Provider First Name:
MANSOOR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
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:
1568646628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 PRESIDENTIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
BALA CYNWYD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19004-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-667-4455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 N PRESIDENTIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-667-4455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2007

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: 122300000X , with the licence number:  DS023126L , 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: 1610569 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1610569 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 172847 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: MA172847 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4517236 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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