1073614285 NPI number — MR. ADAM M WILLIS P.T.

Table of content: MR. ADAM M WILLIS P.T. (NPI 1073614285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073614285 NPI number — MR. ADAM M WILLIS P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
ADAM
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1073614285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH GLENS FALLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12803-5118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-225-5049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 GLEN ST
Provider Second Line Business Practice Location Address:
SUITE #52
Provider Business Practice Location Address City Name:
GLENS FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12801-3584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-538-8778
Provider Business Practice Location Address Fax Number:
518-636-3204
Provider Enumeration Date:
09/26/2006

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: 225100000X , with the licence number:  2305204833 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00010625 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 027046-1 , 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: 0223203 . This is a "DEPARTMENT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6393WI . This is a "REGENCE/BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8944992 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 92527059 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2639WI . This is a "REGENCE/BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2149WI . This is a "REGENCE/BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2305204833 . This is a "LICENSE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com