1619905114 NPI number — HEALTHDRIVE PODIATRY GROUP, PC

Table of content: (NPI 1619905114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619905114 NPI number — HEALTHDRIVE PODIATRY GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHDRIVE PODIATRY GROUP, PC
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:
6
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:
1619905114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CROSSING BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FRAMINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01702-5555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
339-686-2561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 PENNS TRAIL
Provider Second Line Business Practice Location Address:
SUITE 154
Provider Business Practice Location Address City Name:
NEWTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18940-3438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-675-3005
Provider Business Practice Location Address Fax Number:
888-662-0859
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ABBOUD
Authorized Official First Name:
SHADI
Authorized Official Middle Name:
ADIB
Authorized Official Title or Position:
TREASURER/PRACTICE DIRECTOR
Authorized Official Telephone Number:
857-255-0486

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0015488010010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA3720 . This is a "RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 835574 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0055313000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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