1376644096 NPI number — MS. TAVORIA KELLAM MW

Table of content: MS. TAVORIA KELLAM MW (NPI 1376644096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376644096 NPI number — MS. TAVORIA KELLAM MW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLAM
Provider First Name:
TAVORIA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MW
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:
1376644096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1309 5TH AVE
Provider Second Line Business Mailing Address:
#29A
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10029-3123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-876-9448
Provider Business Mailing Address Fax Number:
212-689-3988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1176 5TH AVE
Provider Second Line Business Practice Location Address:
2253 THIRD AVENUE 3RD FL
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10029-6503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-289-6650
Provider Business Practice Location Address Fax Number:
212-360-5088
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: 176B00000X , with the licence number:  F000971-1 , 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: 02692359 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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