1952542615 NPI number — DOMENICK BRACCIA D.O.

Table of content: (NPI 1952542615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952542615 NPI number — DOMENICK BRACCIA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOMENICK BRACCIA D.O.
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:
1952542615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 W CHESTER PIKE
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
HAVERTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19083-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-924-0600
Provider Business Mailing Address Fax Number:
610-924-0627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 W CHESTER PIKE
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
HAVERTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19083-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-924-0600
Provider Business Practice Location Address Fax Number:
610-924-0627
Provider Enumeration Date:
03/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BRACCIA
Authorized Official First Name:
DOMENICK
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
610-924-0600

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  OS006737L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X , with the licence number: OS006737L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X , with the licence number: OS006737L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: OS006737L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X , with the licence number: OS006737L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0012371310008 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1794675 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 648523 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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