=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205491149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREXLER PARK GYNECOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2019
-----------------------------------------------------
Last Update Date | 06/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3131 COLLEGE HEIGHTS BLVD STE 2200B
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-440-3403
-----------------------------------------------------
Fax | 610-433-2395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 N CEDAR CREST BLVD STE 110B
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-2351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-973-1410
-----------------------------------------------------
Fax | 610-973-1449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL BRUCE VIECHNICKI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-440-3403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------