1306824313 NPI number — PHILLGREY INC

Table of content: (NPI 1306824313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306824313 NPI number — PHILLGREY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLGREY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1306824313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWINSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13027-0535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-635-1789
Provider Business Mailing Address Fax Number:
315-635-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASSENA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13662-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-764-5939
Provider Business Practice Location Address Fax Number:
315-764-1172
Provider Enumeration Date:
01/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHERMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
315-764-8195

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02992189 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01911146 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".