1164686242 NPI number — GILA WISEMON CASAC-T

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 1164686242 NPI number — GILA WISEMON CASAC-T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISEMON
Provider First Name:
GILA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CASAC-T
Provider Gender Code:
F

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:
1164686242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31094
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06150-1094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-952-8140
Provider Business Mailing Address Fax Number:
518-952-8287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3619 QUENTIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11234-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-998-7500
Provider Business Practice Location Address Fax Number:
718-998-7955
Provider Enumeration Date:
07/17/2008

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: 101YA0400X , with the licence number:  18895 , 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: 01420795 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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