1881668226 NPI number — JOHN H LACOBOULOS PT

Table of content: JOHN H LACOBOULOS PT (NPI 1881668226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881668226 NPI number — JOHN H LACOBOULOS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACOBOULOS
Provider First Name:
JOHN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1881668226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 CHESTER PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDDYSTONE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19022-1336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-557-9430
Provider Business Mailing Address Fax Number:
866-557-9431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 CHESTER PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDDYSTONE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19022-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-557-9430
Provider Business Practice Location Address Fax Number:
866-557-9431
Provider Enumeration Date:
02/14/2006

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: 225100000X , with the licence number:  PT013028L , 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: 0017783000 . This is a "IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001952664-0003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1952664 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 338203 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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