Provider Demographics
NPI:1174847545
Name:EASTERN PA NEPHROLOGY ASSOC PC
Entity Type:Organization
Organization Name:EASTERN PA NEPHROLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-432-4529
Mailing Address - Street 1:2014 CITY LINE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-2159
Mailing Address - Country:US
Mailing Address - Phone:610-264-5199
Mailing Address - Fax:610-264-5198
Practice Address - Street 1:2014 CITY LINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-2159
Practice Address - Country:US
Practice Address - Phone:610-264-5199
Practice Address - Fax:610-264-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA22191501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical