1790759611 NPI number — MRS. CARROL C CHAMBERS NP

Table of content: MRS. CARROL C CHAMBERS NP (NPI 1790759611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790759611 NPI number — MRS. CARROL C CHAMBERS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERS
Provider First Name:
CARROL
Provider Middle Name:
C
Provider Name Prefix Text:
MRS.
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:
1790759611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4211 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-329-0210
Provider Business Mailing Address Fax Number:
315-329-0215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4211 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-329-0210
Provider Business Practice Location Address Fax Number:
315-329-0215
Provider Enumeration Date:
02/15/2006

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: 363L00000X , with the licence number:  F3009361 , 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: 02185000 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".