1619629243 NPI number — MALLORIE BOSWELL GREENWAY PA

Table of content: MALLORIE BOSWELL GREENWAY PA (NPI 1619629243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619629243 NPI number — MALLORIE BOSWELL GREENWAY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENWAY
Provider First Name:
MALLORIE
Provider Middle Name:
BOSWELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSWELL
Provider Other First Name:
MALLORIE
Provider Other Middle Name:
LEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619629243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23321
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10087-4321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 MAY RIVER XING STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-9732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-985-2520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2022

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4904 . This is a "TENNESSEE DEPARTMENT OF HEALTH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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