1770570459 NPI number — SUSAN FORT SORDONI MD

Table of content: JOHANNA GOMEZ (NPI 1285833491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770570459 NPI number — SUSAN FORT SORDONI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORDONI
Provider First Name:
SUSAN
Provider Middle Name:
FORT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1770570459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-0164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-714-2999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 PIERCE ST
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-5149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-714-2999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2005

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: 207Q00000X , with the licence number:  MD072550L , 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: 0018304560003 . This is a "MED PLUS-3 RIVERS-UNASYN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20 3165381 . This is a "GREAT WEST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0018304560003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20 3165381 . This is a "INTERGROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1058606 . This is a "AETNA MC ADVANTAGE & HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 193973 . This is a "BLUE CROSS-BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 203165381 . This is a "DEVON HEALTH CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7822738 . This is a "AETNA PPL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 002782 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20 3165381 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 60162 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20 3165381 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 61056770 . This is a "DEPT OF LABOR FECA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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