1912262312 NPI number — MS. JILL MASTRANDREA MHC

Table of content: VICKIEANN ROSENBUSCH POREMBA PHARMD (NPI 1063847796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912262312 NPI number — MS. JILL MASTRANDREA MHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTRANDREA
Provider First Name:
JILL
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MHC
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:
1912262312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
69 5TH AVE
Provider Second Line Business Mailing Address:
8A
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10003-3005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-680-0096
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6207 WOODSIDE AVE
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-3576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-898-5085
Provider Business Practice Location Address Fax Number:
718-898-5582
Provider Enumeration Date:
07/11/2012

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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