1760495824 NPI number — DR. RURIK JOHNSON

Table of content: DR. RURIK JOHNSON (NPI 1760495824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760495824 NPI number — DR. RURIK JOHNSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
RURIK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1760495824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 ORCHARD PARK RD
Provider Second Line Business Mailing Address:
A103
Provider Business Mailing Address City Name:
WEST SENECA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14224-2646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-677-5500
Provider Business Mailing Address Fax Number:
716-677-5008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 ORCHARD PARK RD
Provider Second Line Business Practice Location Address:
A103
Provider Business Practice Location Address City Name:
WEST SENECA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14224-2646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-677-5500
Provider Business Practice Location Address Fax Number:
716-677-5008
Provider Enumeration Date:
08/13/2006

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: 208600000X , with the licence number:  229457 , 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: 00028110301 . This is a "UNIVERA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0156830 . This is a "GHI PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000529158001 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00474579 . This is a "RRM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 229457-7W . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02877796 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1714218 . This is a "INDEPENDENT HEALTH" identifier . This identifiers is of the category "OTHER".




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