1053378539 NPI number — DR. ANITA K BUROCK STOTTS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053378539 NPI number — DR. ANITA K BUROCK STOTTS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BUROCK STOTTS

Provider First Name:

ANITA

Provider Middle Name:

K

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1053378539

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/07/2010

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 268

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

GUILDERLAND

Provider Business Mailing Address State Name:

NY

Provider Business Mailing Address Postal Code:

12084-0268

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

518-355-2060

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

100 ANTHONY WAY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

SCHENECTADY

Provider Business Practice Location Address State Name:

NY

Provider Business Practice Location Address Postal Code:

12303-3512

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

518-355-2060

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

04/27/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  165459 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000000093422 . This is a "GHI-HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 000411069004 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 11268278 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 165459-9W . This is a "WORKERS COMP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 5895325 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 391448 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: DB1987 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 10000243 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 108AR1 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 040426006836 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 9720880 . This is a "GHI-PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".