1720496458 NPI number — MICHAEL MCGRAW DPT

Table of content: MICHAEL MCGRAW DPT (NPI 1720496458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720496458 NPI number — MICHAEL MCGRAW DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGRAW
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1720496458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18444-9135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-842-9323
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 6TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONESDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18431-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-228-2142
Provider Business Practice Location Address Fax Number:
570-228-2349
Provider Enumeration Date:
07/25/2014

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: 174400000X , with the licence number:  TPT021560 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT023691 , 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: PT023691 . This is a "STATE LICENSURE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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