1861497893 NPI number — KATHLEEN M MINNICH

Table of content: (NPI 1861497893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861497893 NPI number — KATHLEEN M MINNICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KATHLEEN M MINNICH
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:
1861497893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3632 HILL CHURCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17046-9350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-270-1070
Provider Business Mailing Address Fax Number:
717-273-8373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E PENN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEONA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17042-2429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-270-1070
Provider Business Practice Location Address Fax Number:
717-273-8373
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MINNICH
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
717-270-1070

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 301298 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 301298 . This is a "HEALTH AMERICA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20007524 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1511694 . This is a "GATEWAY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012164090004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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