1639609696 NPI number — MRS. ALICIA TAYLOR BRUSTEIN PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639609696 NPI number — MRS. ALICIA TAYLOR BRUSTEIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUSTEIN
Provider First Name:
ALICIA
Provider Middle Name:
TAYLOR
Provider Name Prefix Text:
MRS.
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:
GARBADE
Provider Other First Name:
ALICIA
Provider Other Middle Name:
TAYLOR
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639609696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 NORTH 21ST STREET
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
CAMP HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-695-6553
Provider Business Mailing Address Fax Number:
855-383-3233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 NORTH 21ST STREET
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
CAMP HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-695-6553
Provider Business Practice Location Address Fax Number:
855-383-3233
Provider Enumeration Date:
06/13/2017

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 , with the licence number:  OA004204 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: MA060420 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MA060420 , 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: MA060420 . This is a "NEW LICENSE NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 103340644 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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