1093778144 NPI number — SHAFER H ZYSMAN

Table of content: SHAFER H ZYSMAN (NPI 1093778144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093778144 NPI number — SHAFER H ZYSMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZYSMAN
Provider First Name:
SHAFER
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093778144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 STILLWATER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST JAMES
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11780-3914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-686-6359
Provider Business Mailing Address Fax Number:
631-647-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 HOWELLS RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BAY SHORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11706-5320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-647-7885
Provider Business Practice Location Address Fax Number:
631-647-7893
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  025669 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01428344 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com