Basic Information
Provider Information | |||||||||
NPI: | 1336120922 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KANOFF | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 W ELM ST | ||||||||
Address2: |   | ||||||||
City: | CONSHOHOCKEN | ||||||||
State: | PA | ||||||||
PostalCode: | 194282007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105676964 | ||||||||
FaxNumber: | 6105676170 | ||||||||
Practice Location | |||||||||
Address1: | 1500 LANSDOWNE AVE | ||||||||
Address2: | SUITE 308 MOB | ||||||||
City: | DARBY | ||||||||
State: | PA | ||||||||
PostalCode: | 190231200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105346142 | ||||||||
FaxNumber: | 6105346130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 05/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | OS003560 | PA | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0008884240004 | 05 | PA |   | MEDICAID | 148829 | 01 | PA | BLUE SHIELD | OTHER | 322006 | 01 | PA | KMHP | OTHER | 4595900 | 01 | PA | AETNA PPO | OTHER | 0052240000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 2610873 | 01 | PA | AETNA HMO | OTHER | 0100215 | 01 | PA | CIGNA | OTHER |