1649210626 NPI number — ANTHONY J. GAGLIARDI M.P.T.

Table of content: MS. MISHMA CHOUDDERY LCSW (NPI 1619565710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649210626 NPI number — ANTHONY J. GAGLIARDI M.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAGLIARDI
Provider First Name:
ANTHONY
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.P.T.
Provider Gender Code:
M

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:
1649210626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 BUTTERFIELD RD STE 1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60515-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
779 W SPROUL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19064-1215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-470-2150
Provider Business Practice Location Address Fax Number:
610-328-9283
Provider Enumeration Date:
06/07/2006

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: 225100000X , with the licence number:  J10002335 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT008422L , 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: 93779901 . This is a "CAREFIRST OF MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000643670 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0237454000 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 650021486 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1649210626 . This is a "CHAMPUS TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5070-0097 . This is a "GHMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11842861 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1649210626 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0237454000 . This is a "IBC AMERIHEALTH" identifier . This identifiers is of the category "OTHER".




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