1629137278 NPI number — DR. DAVID BURTON ROAT D.O.

Table of content: DR. DAVID BURTON ROAT D.O. (NPI 1629137278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629137278 NPI number — DR. DAVID BURTON ROAT D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROAT
Provider First Name:
DAVID
Provider Middle Name:
BURTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROAT
Provider Other First Name:
DAVID
Provider Other Middle Name:
BURTON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D. O.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629137278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4641 ROOSEVELT BLVD
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:
19124-2398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-831-4600
Provider Business Mailing Address Fax Number:
215-831-4700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4641 ROOSEVELT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19124-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-831-4600
Provider Business Practice Location Address Fax Number:
215-831-4700
Provider Enumeration Date:
12/08/2006

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: 2084P0800X , with the licence number:  OS008990L , 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: 0017602440001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: D08036000 . This is a "CONTROLLED DRUG SUBSTANCE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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