1619020112 NPI number — PATRICIA DEITRICH

Table of content: PATRICIA DEITRICH (NPI 1619020112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619020112 NPI number — PATRICIA DEITRICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEITRICH
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1619020112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 PHILADELPHIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15701-3902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-463-7478
Provider Business Mailing Address Fax Number:
724-463-0931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-784-1896
Provider Business Practice Location Address Fax Number:
570-784-1897
Provider Enumeration Date:
01/19/2007

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:  PT005500L , 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: 34765 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 547051 . This is a "HEALTH AMER.ASSUR." identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50066058 . This is a "KHPC-CAPITAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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