Basic Information
| Provider Information | |||||||||
| NPI: | 1487773966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SWITCHBACK MEDICAL CENTER PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1580 CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | JIM THORPE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182291012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703252705 | ||||||||
| FaxNumber: | 5703258310 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | JIM THORPE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182291012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703252705 | ||||||||
| FaxNumber: | 5703258310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5703252705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-023853-E | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH7812 | 01 | RAILROAD MEDICARE | OTHER | 0916600 | 01 | PA | AETNA | OTHER |