1962867077 NPI number — GRANE SUPPLY, INC.

Table of content: (NPI 1962867077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962867077 NPI number — GRANE SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANE SUPPLY, INC.
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:
1962867077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 GAMMA DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15238-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-449-0680
Provider Business Mailing Address Fax Number:
412-968-5800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 E UNION ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19382-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-918-4740
Provider Business Practice Location Address Fax Number:
412-968-5800
Provider Enumeration Date:
12/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HENNELL
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
H
Authorized Official Title or Position:
VICE PRESIDENT OF REIMBURSEMENT
Authorized Official Telephone Number:
412-963-9150

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PP482615 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PP482615 , 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: 100761105-0009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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