1437308343 NPI number — MICHELLE L HARTFORD PAC

Table of content: MICHELLE L HARTFORD PAC (NPI 1437308343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437308343 NPI number — MICHELLE L HARTFORD PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARTFORD
Provider First Name:
MICHELLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1437308343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 SAINT JOSEPHS BLVD
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
ELMIRA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14901-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-271-2050
Provider Business Mailing Address Fax Number:
607-271-2099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 GRAMPIAN BLVD STE 2F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-321-2020
Provider Business Practice Location Address Fax Number:
570-320-7455
Provider Enumeration Date:
09/16/2008

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: 363A00000X , with the licence number:  MA053628 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MA053628 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2109983 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".