1619059367 NPI number — DR. STACEY G WARREN PHD

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 1619059367 NPI number — DR. STACEY G WARREN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARREN
Provider First Name:
STACEY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1619059367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUCKINGHAM
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18912-0215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-750-5525
Provider Business Mailing Address Fax Number:
215-750-5538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
670 WOODBOURNE RD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
LANGHORNE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-750-5525
Provider Business Practice Location Address Fax Number:
215-750-5538
Provider Enumeration Date:
10/20/2006

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: 103G00000X , with the licence number:  PS015003 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103T00000X , with the licence number: PS015003 , 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: 2000582000 . This is a "INDEPENDENCE BLUE CROSS A" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2323243000 . This is a "PERSONAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2626143 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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