1548467061 NPI number — MS. ROSLYN HELENE OWEN RPT

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 1548467061 NPI number — MS. ROSLYN HELENE OWEN RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OWEN
Provider First Name:
ROSLYN
Provider Middle Name:
HELENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALTER
Provider Other First Name:
ROSLYN
Provider Other Middle Name:
HELENE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548467061
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 EDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STORMVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12582-5200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-221-0214
Provider Business Mailing Address Fax Number:
845-221-0214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 EDER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STORMVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12582-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-221-0214
Provider Business Practice Location Address Fax Number:
845-221-0214
Provider Enumeration Date:
06/28/2007

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: 225100000X , with the licence number:  0069501 , 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: 02202853 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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