1720054455 NPI number — MS. ELIZABETH GERTRUDE SALON NP

Table of content: DR. AZRA A FAROOQUI MD (NPI 1366621351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720054455 NPI number — MS. ELIZABETH GERTRUDE SALON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALON
Provider First Name:
ELIZABETH
Provider Middle Name:
GERTRUDE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1720054455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 CULVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850-8782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-277-2201
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 TEMPLE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
OWEGO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13827-1421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-687-5616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2006

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: 363LF0000X , with the licence number:  330406-1 , 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)





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