1689911232 NPI number — LIFE'S JOURNEY OBGYN, PC

Table of content: (NPI 1689911232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689911232 NPI number — LIFE'S JOURNEY OBGYN, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE'S JOURNEY OBGYN, PC
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:
1689911232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 WEST PARK AVENUE
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
DUBOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-371-1900
Provider Business Mailing Address Fax Number:
814-503-8568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 WEST PARK AVENUE
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
DUBOIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-371-1900
Provider Business Practice Location Address Fax Number:
814-503-8568
Provider Enumeration Date:
01/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUCKETT
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
814-371-1900

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  OS014455 , 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: 102334099001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00813924 . This is a "RAILROAD MEDICARE - PALMETTO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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