1700100336 NPI number — ERWIN K BUENASEDA PT

Table of content: ERWIN K BUENASEDA PT (NPI 1700100336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700100336 NPI number — ERWIN K BUENASEDA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUENASEDA
Provider First Name:
ERWIN
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1700100336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1265 WAYNE AVE STE 308
Provider Second Line Business Mailing Address:
119 PROFESSIONAL BUILDING
Provider Business Mailing Address City Name:
INDIANA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15701-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-081-8095
Provider Business Mailing Address Fax Number:
724-801-8147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2701 KIRKWOOD HWY
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19805-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-668-1768
Provider Business Practice Location Address Fax Number:
302-668-1794
Provider Enumeration Date:
03/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  JI-0001072 , 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: 2449064 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2155101 . This is a "HIGHMARK" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 3775507000 . This is a "IBC" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: P01033496 . This is a "MEDIARE RR" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1700100336 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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