Basic Information
| Provider Information | |||||||||
| NPI: | 1649641713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GAUDENZIA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 570 RITCHIE HWY | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211462925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109750067 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194014716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102399600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2015 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4103675551 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
ID Information
| ID | Type | State | Issuer | Description | 417123300 | 05 | MD | MEDICAID | 1366656175 | 01 | MD | COMMERCIAL | OTHER |