1891758694 NPI number — COLLEEN BACKUS PT

Table of content: COLLEEN BACKUS PT (NPI 1891758694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891758694 NPI number — COLLEEN BACKUS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKUS
Provider First Name:
COLLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLEASON
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891758694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 WELLS ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SARATOGA SPRINGS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12866-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-587-0637
Provider Business Mailing Address Fax Number:
518-587-2515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 WELLS ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12866-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-587-0637
Provider Business Practice Location Address Fax Number:
518-587-2515
Provider Enumeration Date:
04/11/2006

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: 225100000X , with the licence number:  006568 , 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: Q55081 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10000074 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2289411 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5683569 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 43115 . This is a "MVP HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000492521001 . This is a "BLUE SHIELD OF NORTHEASTE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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