1649745803 NPI number — NEURO DYNAMICS PENN

Table of content: (NPI 1649745803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649745803 NPI number — NEURO DYNAMICS PENN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEURO DYNAMICS PENN
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:
1649745803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1430
Provider Second Line Business Mailing Address:
LOCKBOX #5120
Provider Business Mailing Address City Name:
JENKS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74034-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-932-2734
Provider Business Mailing Address Fax Number:
918-932-2734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N 18TH ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-770-9333
Provider Business Practice Location Address Fax Number:
918-213-4888
Provider Enumeration Date:
10/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KROTTINGER
Authorized Official First Name:
JAY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
918-932-2734

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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