1942462338 NPI number — ROSEANN VANDERBECK OTR PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942462338 NPI number — ROSEANN VANDERBECK OTR PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEANN VANDERBECK OTR PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1942462338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 CLINTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNBROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-241-3684
Provider Business Mailing Address Fax Number:
516-887-6174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
559 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
EAST ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-872-4605
Provider Business Practice Location Address Fax Number:
516-872-4606
Provider Enumeration Date:
06/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VANDERBECK
Authorized Official First Name:
ROSEANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/ OWNER
Authorized Official Telephone Number:
516-241-3684

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  0029301 , 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)





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