1104919752 NPI number — DR. SARAH L ELMENDORF

Table of content: DR. SARAH L ELMENDORF (NPI 1104919752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104919752 NPI number — DR. SARAH L ELMENDORF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELMENDORF
Provider First Name:
SARAH
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DISTEFANO
Provider Other First Name:
SARAH
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104919752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UPSTATE INFECTIOUS DISEASES ASSOCIATES
Provider Second Line Business Mailing Address:
404 NEW SCOTLAND AVE
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-435-0662
Provider Business Mailing Address Fax Number:
518-435-0664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UPSTATE INFECTIOUS DISEASES ASSOCIATES
Provider Second Line Business Practice Location Address:
404 NEW SCOTLAND AVE
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-435-0662
Provider Business Practice Location Address Fax Number:
518-435-0664
Provider Enumeration Date:
10/02/2006

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: 207RI0200X , with the licence number:  153286 , 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: 000402902001 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 925121 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01051183 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10028381 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".