1427100791 NPI number — ELAN PHOEBE GOLOMB

Table of content: ELAN PHOEBE GOLOMB (NPI 1427100791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427100791 NPI number — ELAN PHOEBE GOLOMB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLOMB
Provider First Name:
ELAN
Provider Middle Name:
PHOEBE
Provider Name Prefix Text:
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:
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:
1427100791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 CLARK ST
Provider Second Line Business Mailing Address:
10E
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11201-2743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-923-0408
Provider Business Mailing Address Fax Number:
212-496-4175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
412 6TH AVE
Provider Second Line Business Practice Location Address:
710
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10011-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-496-6003
Provider Business Practice Location Address Fax Number:
212-496-4175
Provider Enumeration Date:
01/17/2007

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: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V27541 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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