1770819096 NPI number — RUSSELL JOHN ENEDY PA-C

Table of content: RUSSELL JOHN ENEDY PA-C (NPI 1770819096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770819096 NPI number — RUSSELL JOHN ENEDY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENEDY
Provider First Name:
RUSSELL
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1770819096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1086 FRANKLIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15905-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-410-8300
Provider Business Mailing Address Fax Number:
814-410-8331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 FRANKLIN ST
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15905-4330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-536-7851
Provider Business Practice Location Address Fax Number:
814-539-3649
Provider Enumeration Date:
10/21/2009

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: 363A00000X , with the licence number:  MA053940 , 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)





Copyright © 2007-2025 www.npivalidator.com