1700873742 NPI number — DR. JONATHAN H WEISS D.O.

Table of content: DR. JONATHAN H WEISS D.O. (NPI 1700873742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700873742 NPI number — DR. JONATHAN H WEISS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISS
Provider First Name:
JONATHAN
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1700873742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 S 11TH ST STE G8490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-4824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-955-1120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S 11TH ST STE G8490
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-955-1120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2005

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: 207L00000X , with the licence number:  OS7545 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 25MB05619400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: C2-0007023 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: OS006143L , 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: 001263113 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5331307 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00747608 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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