1669669859 NPI number — NICHOLAS DODGE, M.D., P.C.

Table of content: (NPI 1669669859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669669859 NPI number — NICHOLAS DODGE, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICHOLAS DODGE, M.D., P.C.
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:
1669669859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 VOSBURG LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKS SUMMIT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-344-5115
Provider Business Mailing Address Fax Number:
570-344-2123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 E DRINKER ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNMORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18512-2469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-344-5115
Provider Business Practice Location Address Fax Number:
570-344-2123
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DODGE
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-344-5115

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD054271L , 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: 1669669859 . This is a "NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 616633 . This is a "FIRST PRIORITY LIFE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 616633 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 002981 . This is a "FIRST PRIORITY HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DG7762 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0763711000 . This is a "BLUE CARE / BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0015086460006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 616633 . This is a "BLUE SHIELD PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 020395000 . This is a "BLACK LUNG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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