1821441635 NPI number — PROFESSIONAL PODIATRY LLC

Table of content: (NPI 1821441635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821441635 NPI number — PROFESSIONAL PODIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PODIATRY LLC
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:
1821441635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 STONERIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THORNTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19373-1042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-357-6303
Provider Business Mailing Address Fax Number:
484-730-0060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 ORCHARD AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
KENNETT SQUARE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19348-1812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-388-8637
Provider Business Practice Location Address Fax Number:
484-730-0060
Provider Enumeration Date:
07/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KUTVOELGYI
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PODIATRIST/OWNER
Authorized Official Telephone Number:
610-357-6303

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  SC005540 , 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: 521466 . This is a "PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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