Basic Information
Provider Information | |||||||||
NPI: | 1649268293 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | J. | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1245 S CEDAR CREST BLVD | ||||||||
Address2: | SUITE #301 | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181036258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104029099 | ||||||||
FaxNumber: | 6104029029 | ||||||||
Practice Location | |||||||||
Address1: | 1245 S CEDAR CREST BLVD | ||||||||
Address2: | SUITE #301 | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181036258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104029099 | ||||||||
FaxNumber: | 6104029029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2005 | ||||||||
LastUpdateDate: | 08/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD039680L | PA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 000000093574 | 01 | PA | THREE RIVERS | OTHER | 0416119 | 01 | PA | KHP CENTRAL | OTHER | 1010377 | 01 | PW | AMERIHEALTH MERCY | OTHER | 1010377 | 01 | PA | KEYSTONE MERCY | OTHER | 0011694160003 | 05 | PA |   | MEDICAID | 0031980000 | 01 | PA | INDEP BLUE CROSS | OTHER | 416119 | 01 | PA | HIGHMARK | OTHER | 01169416 | 01 | PA | GATEWAY | OTHER |