Provider Demographics
NPI:1104207612
Name:ADVANCED URGENT CARE OF WILLOW GROVE LLC
Entity Type:Organization
Organization Name:ADVANCED URGENT CARE OF WILLOW GROVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKPARVARFARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-441-4267
Mailing Address - Street 1:305 MULBERRY ST
Mailing Address - Street 2:P.O. BOX 957
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1230
Mailing Address - Country:US
Mailing Address - Phone:570-871-4003
Mailing Address - Fax:570-955-0267
Practice Address - Street 1:126 EASTON RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-3203
Practice Address - Country:US
Practice Address - Phone:215-366-7437
Practice Address - Fax:267-607-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424252261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010805460001Medicaid
PAI18051Medicare UPIN
PA083991Medicare PIN