1699759027 NPI number — PROVIDER PLUS, INC

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 1699759027 NPI number — PROVIDER PLUS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDER PLUS, INC
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:
1699759027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 E NORTH LN STE 5075
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONSHOHOCKEN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19428-2490
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:
7750 WINGHAVEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63368-3601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-695-4644
Provider Business Practice Location Address Fax Number:
636-695-4645
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSALESI
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO
Authorized Official Telephone Number:
484-246-9499

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 629896507 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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