1023015500 NPI number — JODY S BLEIER MD

Table of content: JODY S BLEIER MD (NPI 1023015500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023015500 NPI number — JODY S BLEIER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLEIER
Provider First Name:
JODY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023015500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6221 STATE ROUTE 31
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
CICERO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13039-8715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-752-0141
Provider Business Mailing Address Fax Number:
315-752-0142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 W TAFT RD
Provider Second Line Business Practice Location Address:
SUITE 4J
Provider Business Practice Location Address City Name:
LIVERPOOL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13088-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-701-2170
Provider Business Practice Location Address Fax Number:
315-701-2186
Provider Enumeration Date:
06/30/2005

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: 207RC0000X , with the licence number:  136547 , 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: 00714512 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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