1043275969 NPI number — OPTUM INFUSION SERVICES 100, INC.

Table of Contents

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

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".




Copyright © 2007-2025 www.npivalidator.com