Basic Information
| Provider Information | |||||||||
| NPI: | 1851543516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YESALAVAGE | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181045622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106288372 | ||||||||
| FaxNumber: | 6106288648 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 S CEDAR CREST BLVD | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104029099 | ||||||||
| FaxNumber: | 6104029029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN518009-L | PA | N | Nursing Service Providers | Registered Nurse | 367500000X | 081789 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1024154190002 | 05 | PA | MEDICAID | 3633568000 | 01 | PA | IBC | OTHER | 9358458 | 01 | PA | AETNA | OTHER | 121176 | 01 | PA | GEISINGER | OTHER | 2082635 | 01 | PA | FIRST PRIORITY | OTHER | 50081140 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 11945331 | 01 | PA | CAQH | OTHER | 1585282 | 01 | PA | GATEWAY | OTHER | 2082635 | 01 | PA | HIGHMARK | OTHER |