1720050289 NPI number — DERIENZO FAMILY PRACTICE

Table of content: DR. SAMUEL JOHN RANDALL III DDS (NPI 1609896331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720050289 NPI number — DERIENZO FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERIENZO FAMILY PRACTICE
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:
1720050289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 ARENTZEN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLEROI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15022-1085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-483-3581
Provider Business Mailing Address Fax Number:
724-483-3483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 ARENTZEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLEROI
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15022-1085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-483-3581
Provider Business Practice Location Address Fax Number:
724-483-3483
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DERIENZO
Authorized Official First Name:
UMBERTO
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
724-483-3581

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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