Provider Demographics
NPI:1851423784
Name:EAGLE CHIROPRACTIC AT POTTSTOWN
Entity Type:Organization
Organization Name:EAGLE CHIROPRACTIC AT POTTSTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:610-469-0700
Mailing Address - Street 1:2091 POTTSTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19465-8671
Mailing Address - Country:US
Mailing Address - Phone:610-469-0700
Mailing Address - Fax:610-469-8502
Practice Address - Street 1:2091 POTTSTOWN PIKE
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19465-8671
Practice Address - Country:US
Practice Address - Phone:610-469-0700
Practice Address - Fax:610-469-8502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004743L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA673170OtherPERSONAL CHOICE
PA5931123OtherAETNA
PA00139115004Medicaid
PA673170OtherPERSONAL CHOICE
PA675143Medicare ID - Type Unspecified
PA673170Medicare ID - Type Unspecified
PAU73043Medicare UPIN