1588653661 NPI number — DR. GAULT M FARRELL MD

Table of content: DR. GAULT M FARRELL MD (NPI 1588653661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588653661 NPI number — DR. GAULT M FARRELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARRELL
Provider First Name:
GAULT
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1588653661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 MARGARET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLATTSBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12901-1755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-566-2020
Provider Business Mailing Address Fax Number:
518-561-5390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 MARGARET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901-1755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-566-2020
Provider Business Practice Location Address Fax Number:
518-561-5390
Provider Enumeration Date:
10/20/2005

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: 174400000X , with the licence number:  213607 , 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: 213607 . This is a "LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000402108001 . This is a "BLUE SHIELD OF NORTHEASTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 424B3 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01433123 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2136077 . This is a "WC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 400638 . This is a "MVP SELECT CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107286 . This is a "BC UTICA" identifier . This identifiers is of the category "OTHER".




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