1689661092 NPI number — MS. DOROTHEA BURGET SOUTHWICK P.T.

Table of content: MS. DOROTHEA BURGET SOUTHWICK P.T. (NPI 1689661092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689661092 NPI number — MS. DOROTHEA BURGET SOUTHWICK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHWICK
Provider First Name:
DOROTHEA
Provider Middle Name:
BURGET
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1689661092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 702
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPLAIN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-298-1111
Provider Business Mailing Address Fax Number:
518-298-1111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 BEEMAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPLAIN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-298-1111
Provider Business Practice Location Address Fax Number:
518-298-1111
Provider Enumeration Date:
09/30/2005

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: 225100000X , with the licence number:  0065281 , 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: 000405998001 . This is a "BLUE SHIELD OF NORTHEASTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: Q66832 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 110409700 . This is a "US DEPT OF LABOR OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: Q66831 . This is a "EMPIRE BLUE CROSS/EMPIRE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141733498 . This is a "EMPIRE STATE PLAN GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: GRP405998002 . This is a "BLUE SHIELD OF NORTHEASTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 650005243 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 819687 . This is a "EMPIRE STATE PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141733498 . This is a "EXCELLUS BLUE CROSS BLUE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P01010652 . This is a "EXCELLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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