1710001136 NPI number — PMSI DIVISION OF CARDIOLOGY

Table of content: (NPI 1710001136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710001136 NPI number — PMSI DIVISION OF CARDIOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PMSI DIVISION OF CARDIOLOGY
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:
6
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:
1710001136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1591 MEDICAL DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-326-8005
Provider Business Mailing Address Fax Number:
610-718-0788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1591 MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-326-8005
Provider Business Practice Location Address Fax Number:
610-718-0788
Provider Enumeration Date:
03/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ENOCHS
Authorized Official First Name:
SHANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
610-327-4200

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD044234E ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: MD062953L ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 919371 . This is a "BLUE SHIELD ASSIGN. ACCT" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0859976000 . This is a "KEYSTONE HMO" identifier . This identifiers is of the category "OTHER".