Basic Information
Provider Information | |||||||||
NPI: | 1669417663 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REDSTONE | ||||||||
FirstName: | ELLEN | ||||||||
MiddleName: | ALICE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 95 HIGHLAND AVE | ||||||||
Address2: | SUITE 130 | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180179424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108681100 | ||||||||
FaxNumber: | 6108681111 | ||||||||
Practice Location | |||||||||
Address1: | 3735 NAZARETH RD | ||||||||
Address2: | SUITE 206 | ||||||||
City: | EASTON | ||||||||
State: | PA | ||||||||
PostalCode: | 180458338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4845038281 | ||||||||
FaxNumber: | 4845038200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 11/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | MD067870L | PA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | 01750444 | 05 | PA |   | MEDICAID |