1962487264 NPI number — MR. EDWARD D MANZELLA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962487264 NPI number — MR. EDWARD D MANZELLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANZELLA
Provider First Name:
EDWARD
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1962487264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 N CEDAR CREST BLVD STE 110B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18104-2351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-973-1410
Provider Business Mailing Address Fax Number:
610-973-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1353 STATE ROUTE 903
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JIM THORPE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18229-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-325-8393
Provider Business Practice Location Address Fax Number:
570-325-8029
Provider Enumeration Date:
12/08/2005

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: 207R00000X , with the licence number:  MD047252L , 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: 2420346000 . This is a "PERSONAL CHOICE BLUE SHIE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03277901 . This is a "CAPITAL BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1753980 . This is a "FEDERAL BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 810651818 . This is a "COVENTRY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110101 . This is a "AMERIHEALTH ADMIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 810651818 . This is a "TRICARE REGION I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03277800 . This is a "CAPITAL BLUE CROSS GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00387554 . This is a "PALMETTO GBA GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001442722 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20031254 . This is a "AMERIHEALTH MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 810651818 . This is a "STERLING OPTION I GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1753980 . This is a "AMERIHEALTH ADMIN GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010654900 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110101 . This is a "PA BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5389099 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6002088 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0274540000 . This is a "PERSONAL CHOICE BLUE SHIE" identifier . This identifiers is of the category "OTHER".




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