1154400240 NPI number — KIRBY JANKE DC

Table of content: KIRBY JANKE DC (NPI 1154400240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154400240 NPI number — KIRBY JANKE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANKE
Provider First Name:
KIRBY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1154400240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 W FAYETTE ST
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13204-2859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-472-1488
Provider Business Mailing Address Fax Number:
315-476-1792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 FENNELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKANEATELES
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13152-1137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-685-1655
Provider Business Practice Location Address Fax Number:
315-685-1657
Provider Enumeration Date:
11/02/2006

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: 111N00000X , with the licence number:  PT007472 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT007472 , 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: 109818600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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