1720012826 NPI number — JOHN T QUEENAN JR. M.D.

Table of content: JOHN T QUEENAN JR. M.D. (NPI 1720012826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720012826 NPI number — JOHN T QUEENAN JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUEENAN
Provider First Name:
JOHN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1720012826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
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 668
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:
585-275-0638
Provider Business Mailing Address Fax Number:
585-273-3359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
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:
585-275-4065
Provider Business Practice Location Address Fax Number:
585-756-5717
Provider Enumeration Date:
07/11/2006

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: 207VE0102X , with the licence number:  218840 , 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: P010218840 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: MDF691 . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02104745 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P010218840 . This is a "BLUE SHIELD OF ROCHESTER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4935069 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".