1770774473 NPI number — FRANKLIN A ANTOSH MPT

Table of content: FRANKLIN A ANTOSH MPT (NPI 1770774473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770774473 NPI number — FRANKLIN A ANTOSH MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTOSH
Provider First Name:
FRANKLIN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1770774473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 ROUTE 113 STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUDERTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18964-1022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-721-1024
Provider Business Mailing Address Fax Number:
215-721-2081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 ROUTE 113 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUDERTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18964-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-721-1024
Provider Business Practice Location Address Fax Number:
215-721-2081
Provider Enumeration Date:
08/07/2007

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: 225100000X , with the licence number:  PT018877 , 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: 001977279 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50071451 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7205900 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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