1811100068 NPI number — NEUROPSYCHOLOGY SERVICE PA

Table of content: (NPI 1811100068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811100068 NPI number — NEUROPSYCHOLOGY SERVICE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROPSYCHOLOGY SERVICE PA
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:
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:
1811100068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
277 STATE ST
Provider Second Line Business Mailing Address:
SUITE 2A
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04401-5439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-990-2580
Provider Business Mailing Address Fax Number:
207-990-1930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 STATE STREET
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-5440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-990-2580
Provider Business Practice Location Address Fax Number:
207-990-1930
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRUENEICH
Authorized Official First Name:
ROYAL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-990-2580

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5418635 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P0724 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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