1104829472 NPI number — GENA R KORRELL MPT, CERT, MDT

Table of content: GENA R KORRELL MPT, CERT, MDT (NPI 1104829472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104829472 NPI number — GENA R KORRELL MPT, CERT, MDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORRELL
Provider First Name:
GENA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT, CERT, MDT
Provider Gender Code:
F

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:
1104829472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 CORRINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST CHESTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19382-6781
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-793-3514
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2323 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19806-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-888-2551
Provider Business Practice Location Address Fax Number:
302-888-2571
Provider Enumeration Date:
05/31/2005

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: 225100000X , with the licence number:  J0000744 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT002780E , 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: 7043347 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: UP1205 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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