1821138165 NPI number — DR. PATSY M IANNOLO M.D.

Table of content: DR. PATSY M IANNOLO M.D. (NPI 1821138165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821138165 NPI number — DR. PATSY M IANNOLO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IANNOLO
Provider First Name:
PATSY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1821138165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 346
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13212-0346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-458-4622
Provider Business Mailing Address Fax Number:
315-458-9629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5180 W TAFT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
N SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13212-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-458-4622
Provider Business Practice Location Address Fax Number:
315-458-9629
Provider Enumeration Date:
02/07/2007

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: 207P00000X , with the licence number:  155664 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 155664 , 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)