1770790974 NPI number — BLOOMSBURG PHYSICIAN SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770790974 NPI number — BLOOMSBURG PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMSBURG PHYSICIAN SERVICES
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:
6
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:
1770790974
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:
410 GLENN AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
BLOOMSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17815-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-387-2339
Provider Business Mailing Address Fax Number:
570-387-2487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 GLENN AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BLOOMSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17815-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-387-2339
Provider Business Practice Location Address Fax Number:
570-387-2487
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEVITO
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
570-387-2148

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50052731 . This is a "CBC NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0014107290004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 739865 . This is a "HIGHMARK NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 8807 . This is a "GHP NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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