Provider Demographics
NPI:1982984530
Name:PROFILE SHOP, INC.
Entity Type:Organization
Organization Name:PROFILE SHOP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GESUALDI
Authorized Official - Suffix:
Authorized Official - Credentials:CMF
Authorized Official - Phone:215-355-5788
Mailing Address - Street 1:3300 TILLMAN DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2071
Mailing Address - Country:US
Mailing Address - Phone:215-633-3461
Mailing Address - Fax:215-633-3567
Practice Address - Street 1:45 SECOND STREET PIKE
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3806
Practice Address - Country:US
Practice Address - Phone:215-355-5788
Practice Address - Fax:215-355-5778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFILE SHOP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000005802332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4273570002Medicare NSC