1225017130 NPI number — RIDGE CREST INC

Table of content: (NPI 1225017130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225017130 NPI number — RIDGE CREST INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIDGE CREST 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:
1225017130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 LAKESIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-355-6288
Provider Business Mailing Address Fax Number:
215-355-8127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 BUCK ROAD NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEASTERVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-355-3131
Provider Business Practice Location Address Fax Number:
215-355-0481
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEGAL
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-355-6288

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  A06720 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 314000000X , with the licence number: 181102 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 23145 . This is a "HEALTH PARTNERS/SR. PART." identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1039755 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 86246 . This is a "AETNA / US HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1169850001 . This is a "DMERC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0005766000 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012017830001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0120178301 . This is a "AMERICHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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