1760572903 NPI number — VLADIMIR MEDVED

Table of content: VLADIMIR MEDVED (NPI 1760572903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760572903 NPI number — VLADIMIR MEDVED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDVED
Provider First Name:
VLADIMIR
Provider Middle Name:
Provider Name Prefix Text:
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:
1760572903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALONE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12953-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-481-6044
Provider Business Mailing Address Fax Number:
518-481-6043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALONE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12953-1350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-481-6044
Provider Business Practice Location Address Fax Number:
518-481-6043
Provider Enumeration Date:
10/16/2006

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: 207Q00000X , with the licence number:  221956 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 221956 , 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: 02410126 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5996910 . This is a "GHI FAMILY HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 364145 . This is a "MVP HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010221956 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P00189181 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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