1366487720 NPI number — MITRE GASTROENTEROLOGY ASSOCIATES

Table of content: (NPI 1366487720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366487720 NPI number — MITRE GASTROENTEROLOGY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MITRE GASTROENTEROLOGY ASSOCIATES
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:
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:
1366487720
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:
925 BRIGHTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15233-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-321-1648
Provider Business Mailing Address Fax Number:
412-321-4216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 BRIGHTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15233-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-321-1648
Provider Business Practice Location Address Fax Number:
412-321-4216
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITRE
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
412-321-1648

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  MD032806L , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1009520810001 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1568734 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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