Healthcare Provider Details

I. General information

NPI: 1962834077
Provider Name (Legal Business Name): BRIAN ABALUCK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 INDUSTRIAL BLVD STE 100
PAOLI PA
19301-1645
US

IV. Provider business mailing address

2 INDUSTRIAL BLVD STE 100
PAOLI PA
19301-1645
US

V. Phone/Fax

Practice location:
  • Phone: 484-565-1358
  • Fax: 484-565-1312
Mailing address:
  • Phone: 484-565-1358
  • Fax: 484-565-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD4455233
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberMD4455233
License Number StatePA

VIII. Authorized Official

Name: BRIAN K ABALUCK
Title or Position: CEO
Credential: MD
Phone: 484-565-1358