1265461776 NPI number — BREEANA GILLETT PA

Table of content: BREEANA GILLETT PA (NPI 1265461776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265461776 NPI number — BREEANA GILLETT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLETT
Provider First Name:
BREEANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1265461776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 ELMWOOD AVE
Provider Second Line Business Mailing Address:
BOX 655
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14642-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-341-6880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
BOX 655
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14642-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-341-6880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2006

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: 363A00000X , with the licence number:  8746 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 0087461 , 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: P00149815 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000570415001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00011220501 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 161480107 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01618542 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 050304000023 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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