1649271180 NPI number — JOHN R WALSH DO

Table of content: JOHN R WALSH DO (NPI 1649271180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649271180 NPI number — JOHN R WALSH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSH
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1649271180
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:
3624 MARKET ST
Provider Second Line Business Mailing Address:
SUITE 560W
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-2286
Provider Business Mailing Address Fax Number:
215-615-0500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 E MARSHALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19380-5414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-696-8900
Provider Business Practice Location Address Fax Number:
610-696-3890
Provider Enumeration Date:
08/09/2005

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: 207R00000X , with the licence number:  05-006953-L , 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: 1294915 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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