1649206327 NPI number — 3809 BAYSHORE ROAD OPERATIONS LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649206327 NPI number — 3809 BAYSHORE ROAD OPERATIONS LLC

Employer Identification Number (EIN):

Provider Organization Name:

3809 BAYSHORE ROAD OPERATIONS LLC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

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:

1649206327

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

06/12/2015

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

101 E STATE ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

KENNETT SQUARE

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

19348-3109

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

610-925-4436

Provider Business Mailing Address Fax Number:

610-925-4351

Provider First Line Business Practice Location Address:

3809 BAYSHORE RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

NORTH CAPE MAY

Provider Business Practice Location Address State Name:

NJ

Provider Business Practice Location Address Postal Code:

08204-3259

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

609-898-0677

Provider Business Practice Location Address Fax Number:

609-898-1186

Provider Enumeration Date:

06/24/2006

Authorized Official Last Name:

KIELER

Authorized Official First Name:

WALTER

Authorized Official Middle Name:

Authorized Official Title or Position:

PRESIDENT

Authorized Official Telephone Number:

505-468-4742

• Taxonomy code: 314000000X , with the licence number:  060508 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 316929 . This is a "US FAMILY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
• Identifier: 62-1518645 . This is a "CONSUMER HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".
• Identifier: 489813 . This is a "AETNA-HMO" identifier . This identifiers is of the category "OTHER".
• Identifier: 4471709 . This is a "UNISYS #" identifier . This identifiers is of the category "OTHER".
• Identifier: 62-1518645 . This is a "AETNA-NONHMO" identifier . This identifiers is of the category "OTHER".
• Identifier: 0006179000 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 0261173 . This is a "MOLINA #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 315281 . This is a "HORIZON - SNF" identifier . This identifiers is of the category "OTHER".
• Identifier: 62-1518645 . This is a "HNFS-TRICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 62-1518645 . This is a "CIGNA-NJ" identifier . This identifiers is of the category "OTHER".
• Identifier: 000852 . This is a "HORIZON - SUB" identifier . This identifiers is of the category "OTHER".
• Identifier: 05400 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
• Identifier: 62-1518645 . This is a "HCPC" identifier . This identifiers is of the category "OTHER".