Basic Information
| Provider Information | |||||||||
| NPI: | 1346203171 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE SERVICES LOWER BUCKS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LBH PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 BATH RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190073101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157859200 | ||||||||
| FaxNumber: | 2157859039 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 BATH RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190073101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157859200 | ||||||||
| FaxNumber: | 2157859039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 04/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SAVITALA | ||||||||
| AuthorizedOfficialFirstName: | RADHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 9092354309 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIME HEALTHCARE SERVICES LOWER BUCKS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100745380 002 | 05 | PA | MEDICAID | 000348728 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 30012055 | 01 | PA | KEYSTONE MERCY | OTHER | 0776018000 | 01 | PA | IBC | OTHER |