Healthcare Provider Details

I. General information

NPI: 1174847545
Provider Name (Legal Business Name): EASTERN PA NEPHROLOGY ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 CITY LINE RD SUITE 101
BETHLEHEM PA
18017-2159
US

IV. Provider business mailing address

2014 CITY LINE RD SUITE 101
BETHLEHEM PA
18017-2159
US

V. Phone/Fax

Practice location:
  • Phone: 610-264-5199
  • Fax: 610-264-5198
Mailing address:
  • Phone: 610-264-5199
  • Fax: 610-264-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number22191501
License Number StatePA

VIII. Authorized Official

Name: DOUGLAS JOHNSON
Title or Position: OWNER
Credential: MD
Phone: 610-432-4529