1386632628 NPI number — BRIODY HEALTH CARE FACILTIY LLC

Table of content: (NPI 1386632628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386632628 NPI number — BRIODY HEALTH CARE FACILTIY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIODY HEALTH CARE FACILTIY LLC
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:
1386632628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOCKPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14094-6142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-434-6361
Provider Business Mailing Address Fax Number:
716-434-6396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCKPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14094-6142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-434-6361
Provider Business Practice Location Address Fax Number:
716-434-6396
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PETOCK
Authorized Official First Name:
ANN
Authorized Official Middle Name:
BRIODY
Authorized Official Title or Position:
ADMINISTRATOR/OWNER
Authorized Official Telephone Number:
716-434-6361

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  3101300N , 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: 000626997001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 080047479 . This is a "PALMETTO GBA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: T5 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000624931001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000670038001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000670088001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000508042004 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0109980 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000219000 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00011419701 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00475443 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010070502 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000624932001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000626902001 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000640005006 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 80084A . This is a "UPSTATE MEDICARE PART B" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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