Basic Information
| Provider Information | |||||||||
| NPI: | 1508899428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8500-6335 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158078000 | ||||||||
| FaxNumber: | 2158078235 | ||||||||
| Practice Location | |||||||||
| Address1: | 3998 RED LION RD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191141436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | 2156124532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
| 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 | 207P00000X | MD030609E | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00997741-02 | 01 | PA | AMERICHOICE- TORRES | OTHER | 00997741-03 | 01 | PA | AMERICHOICE- FRANKFORD | OTHER | 1111168 | 01 | PA | KEYSTONE MERCY | OTHER | 452729 | 01 | PA | AETNA CONTRACT | OTHER | 00997741-04 | 01 | PA | AMERICHOICE - BUCKS | OTHER | 0009977410009 | 05 | PA | MEDICAID | 20045128 | 01 | PA | AMERIHEALTH MERCY | OTHER | 0009977410007 | 05 | PA | MEDICAID | 0058423000 | 01 | PA | KEYSTONE IBC | OTHER | 07645 | 01 | PA | HEALTH PARTNERS | OTHER | 086062 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 086062 | 01 | PA | PERSONAL CHOICE | OTHER | 5655559 | 01 | PA | CIGNA | OTHER | 0009977410008 | 05 | PA | MEDICAID |