1578032769 NPI number — LISA R KANFOUSH OD

Table of content: (NPI 1578032769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578032769 NPI number — LISA R KANFOUSH OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISA R KANFOUSH OD
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:
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:
1578032769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 PLEASANT DR STE 4U
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALIQUIPPA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15001-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-622-6467
Provider Business Mailing Address Fax Number:
724-378-4547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 PLEASANT DR STE 4U
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALIQUIPPA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15001-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-622-6467
Provider Business Practice Location Address Fax Number:
724-378-4547
Provider Enumeration Date:
11/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KANFOUSH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
724-378-4457

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0009739462 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1003814559 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 065944RBR . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 11149961050 . This is a "NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 314110 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004329329 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1114996105 . This is a "NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 312055 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 701466 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1003814559 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1547972 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 251892272 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2792074 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 92272 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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