1568654069 NPI number — MR. GREGORY JEBLONSKI DPT

Table of content: MR. GREGORY JEBLONSKI DPT (NPI 1568654069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568654069 NPI number — MR. GREGORY JEBLONSKI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEBLONSKI
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1568654069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 W 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARCUS HOOK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19061-4513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-859-8850
Provider Business Mailing Address Fax Number:
610-859-7876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 ARAMINGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19134-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-203-1930
Provider Business Practice Location Address Fax Number:
215-203-1931
Provider Enumeration Date:
08/17/2007

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: 225100000X , with the licence number:  PT-018686 , 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: 30069505 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3760849000 . This is a "IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2147754 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 301069 . This is a "UNISON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102415114-0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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