1801919915 NPI number — BANCROFT NEUROHEALTH

Table of content: MOHAMED KHALED EZZ ELDIN MD (NPI 1952097388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801919915 NPI number — BANCROFT NEUROHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANCROFT NEUROHEALTH
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:
1801919915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 OLD LANCASTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERION STATION
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19066-1526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-747-0290
Provider Business Mailing Address Fax Number:
610-747-0294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2603 SPRINGFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOMALL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19008-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-325-2851
Provider Business Practice Location Address Fax Number:
610-353-4056
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS-TAYLOR
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
SENIOR DIRECTOR
Authorized Official Telephone Number:
610-747-0290

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  135180 , 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: 101112176-0031 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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