1932412467 NPI number — M COLLETTE BRANDT

Table of content: M COLLETTE BRANDT (NPI 1932412467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932412467 NPI number — M COLLETTE BRANDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDT
Provider First Name:
M COLLETTE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRANDT
Provider Other First Name:
MARY
Provider Other Middle Name:
COLLETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA/L, B.S
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932412467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 HEDGE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COAL TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17866-7719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-975-9434
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 FORD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19131-2833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-877-3110
Provider Business Practice Location Address Fax Number:
215-871-3110
Provider Enumeration Date:
07/26/2010

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: 224Z00000X , with the licence number:  OP001163L , 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: 1932412467 . This is a "COTA/L" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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