1720673411 NPI number — COLUMBIA ANCILLARY SERVICES INC

Table of content: (NPI 1720673411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720673411 NPI number — COLUMBIA ANCILLARY SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA ANCILLARY SERVICES INC
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:
1720673411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1388 STATE RT 487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815-8953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-784-1410
Provider Business Mailing Address Fax Number:
570-784-0864

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6850 LOWS RD
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-8708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-784-5300
Provider Business Practice Location Address Fax Number:
570-784-5301
Provider Enumeration Date:
03/04/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KLINGERMAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-784-0111

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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