1598741126 NPI number — BRUCE CARNIVALE DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598741126 NPI number — BRUCE CARNIVALE DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CARNIVALE

Provider First Name:

BRUCE

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

Provider Gender Code:

M

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:

1598741126

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/21/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2450 W HUNTING PARK AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PHILADELPHIA

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

19129-1302

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

215-707-3008

Provider Business Mailing Address Fax Number:

215-707-1387

Provider First Line Business Practice Location Address:

3401 N BROAD ST

Provider Second Line Business Practice Location Address:

7TH FLOOR OUT PATIENT BUILDING

Provider Business Practice Location Address City Name:

PHILADELPHIA

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

19140-5103

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

215-707-3008

Provider Business Practice Location Address Fax Number:

215-707-1387

Provider Enumeration Date:

12/15/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  OS 007278L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 4476096 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 045941 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 3122336 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0678844 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1016307 . This is a "KEYSTONE MERCY HEALTH PLA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 597586 . This is a "MEDICARE GROUP TPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 0146198902 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 001461989 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 0717488000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: CD4829 . This is a "RR MEDICARE TPI GROUPS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: P00025012 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".