1043275969 NPI number — OPTUM INFUSION SERVICES 100, INC.

Table of content: (NPI 1043275969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043275969 NPI number — OPTUM INFUSION SERVICES 100, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUM INFUSION SERVICES 100, 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:
1043275969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
931 D CONKLIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-346-6348
Provider Business Mailing Address Fax Number:
866-689-3569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
931 D CONKLIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-346-6348
Provider Business Practice Location Address Fax Number:
866-689-3569
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OBERG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, COMPLIANCE
Authorized Official Telephone Number:
499-988-5893

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X , with the licence number:  9296L0001 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X , with the licence number: 020477 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 85329 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: ANC1772 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9296L001 . This is a "HOME CARE SERVICE AGENCY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 58658 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: B6A532 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 114382 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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