1790104701 NPI number — ELEANOR GILLIS

Table of content: ELEANOR GILLIS (NPI 1790104701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790104701 NPI number — ELEANOR GILLIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLIS
Provider First Name:
ELEANOR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1790104701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
491 ALLENDALE RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-785-2897
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 TOWNSHIP LINE RD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YARDLEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19067-5567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-860-3360
Provider Business Practice Location Address Fax Number:
215-860-3362
Provider Enumeration Date:
04/08/2014

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: 2085N0904X , with the licence number:  25MA10912200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: MD462331 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 25MA10912200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 278093 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD462331 , 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)