1700828134 NPI number — EPMG OF PENNSYLVANIA, P.C.

Table of content: (NPI 1700828134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700828134 NPI number — EPMG OF PENNSYLVANIA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPMG OF PENNSYLVANIA, P.C.
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:
1700828134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 GREEN RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-1598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-466-3764
Provider Business Mailing Address Fax Number:
734-995-2913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PECKVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18452-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-489-7546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
800-466-3764

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: EP1784066 . This is a "BC/BS HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016957360006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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