1821062241 NPI number — JEANANNE M GIBEAULT N.P.

Table of content: JEANANNE M GIBEAULT N.P. (NPI 1821062241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821062241 NPI number — JEANANNE M GIBEAULT N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBEAULT
Provider First Name:
JEANANNE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
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:
1821062241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
730 S CROUSE AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13210-1713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-234-6699
Provider Business Mailing Address Fax Number:
315-234-4807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
739 IRVING AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-1640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-234-6677
Provider Business Practice Location Address Fax Number:
315-234-4808
Provider Enumeration Date:
02/14/2006

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:  F3322891 , 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: 02056962 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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