1922169200 NPI number — DR. LYNNITA M TIGUE-PETROSKI DC

Table of content: DR. LYNNITA M TIGUE-PETROSKI DC (NPI 1922169200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922169200 NPI number — DR. LYNNITA M TIGUE-PETROSKI DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIGUE-PETROSKI
Provider First Name:
LYNNITA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIGUE
Provider Other First Name:
LYNNITA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922169200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 FOREST DR
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
LORDS VALLEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18428-6140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-775-6205
Provider Business Mailing Address Fax Number:
570-775-6205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 FOREST DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
LORDS VALLEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18428-6140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-775-6205
Provider Business Practice Location Address Fax Number:
570-775-6205
Provider Enumeration Date:
12/12/2006

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: 111N00000X , with the licence number:  DC008740 , 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: 1012312930001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 818148 . This is a "FIRST PRIORITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1640258 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 056426TEX . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 201331634 . This is a "TAX ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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