1639198435 NPI number — SUSAN B CONLEY MD

Table of content: SUSAN B CONLEY MD (NPI 1639198435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639198435 NPI number — SUSAN B CONLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONLEY
Provider First Name:
SUSAN
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1639198435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3601 A ST
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:
19134-1043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-427-5190
Provider Business Mailing Address Fax Number:
215-427-5351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 A ST
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:
19134-1043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-427-5190
Provider Business Practice Location Address Fax Number:
215-427-5351
Provider Enumeration Date:
07/19/2006

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: 2080P0210X , with the licence number:  MD063184L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0210X , with the licence number: 25MA07963200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0016642200003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7527608 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2748937000 . This is a "AMERIHEALTH KEYSTONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60025871 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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