1902048762 NPI number — INDEPENDENCE CORPORATION

Table of content: (NPI 1902048762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902048762 NPI number — INDEPENDENCE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE CORPORATION
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:
1902048762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4119 MAUCH CHUNK RD # C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COPLAY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18037-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-799-2020
Provider Business Mailing Address Fax Number:
610-799-4399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1545 N 9TH ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-9266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-424-9988
Provider Business Practice Location Address Fax Number:
570-424-9697
Provider Enumeration Date:
03/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PAUSINGER
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE A/R
Authorized Official Telephone Number:
610-799-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018518950002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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