1245765692 NPI number — COURTNEY MARRA

Table of content: COURTNEY MARRA (NPI 1245765692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245765692 NPI number — COURTNEY MARRA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRA
Provider First Name:
COURTNEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1245765692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79 GLENRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12302-4523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-952-8408
Provider Business Mailing Address Fax Number:
518-952-8287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 OLD ROUTE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10512-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-225-5202
Provider Business Practice Location Address Fax Number:
845-704-6178
Provider Enumeration Date:
04/24/2017

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 ; 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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