1710315569 NPI number — ANNE E WILMOTH

Table of content: ANNE E WILMOTH (NPI 1710315569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710315569 NPI number — ANNE E WILMOTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILMOTH
Provider First Name:
ANNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1710315569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 CLINTON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-3362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-333-8277
Provider Business Mailing Address Fax Number:
814-333-6203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 CLINTON CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-333-8277
Provider Business Practice Location Address Fax Number:
814-333-6203
Provider Enumeration Date:
10/14/2013

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: 363A00000X , with the licence number:  MA056342 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: MA056342 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P01510431 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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