1366448599 NPI number — DR. ELLEN CELESTE GAUGHAN MD

Table of content: DR. ELLEN CELESTE GAUGHAN MD (NPI 1366448599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366448599 NPI number — DR. ELLEN CELESTE GAUGHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAUGHAN
Provider First Name:
ELLEN
Provider Middle Name:
CELESTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1366448599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/15/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 MARGARET STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
PLATTSBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12901-1874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-566-8603
Provider Business Mailing Address Fax Number:
518-566-8582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 MARGARET STREET
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901-1874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-566-8603
Provider Business Practice Location Address Fax Number:
518-566-8582
Provider Enumeration Date:
06/22/2005

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: 2084N0400X , with the licence number:  213308 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: 213308 , 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: 000495471003 . This is a "BLUE SHIELD OF NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010213308 . This is a "BC OF UTICA WATERTOWN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01998998 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130023170 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141826450 . This is a "TRICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 8C1231 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141826450 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 110639300 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 698338 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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