1649311325 NPI number — NANTICOKE GASTROENTEROLOGY, P.A.

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 1649311325 NPI number — NANTICOKE GASTROENTEROLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NANTICOKE GASTROENTEROLOGY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1649311325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 MIDDLEFORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEAFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19973-3604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-629-2229
Provider Business Mailing Address Fax Number:
302-629-2285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 MIDDLEFORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-629-2229
Provider Business Practice Location Address Fax Number:
302-629-2285
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACKLER
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
302-629-2229

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  C10004336 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1939 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0000825302 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 421862 . This is a "OPT CHOICE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 0916029 00 . This is a "MARYLAND MEDICAID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 100010338 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2714 . This is a "CAREFIRST" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 421862 . This is a "MDIPA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 505182 . This is a "AETNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: T266 . This is a "BLUECROSS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 085567809 . This is a "CHAMPUS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: PAL58270210001 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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