1174629778 NPI number — STACIA BETH BIRDSALL CNM

Table of content: STACIA BETH BIRDSALL CNM (NPI 1174629778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174629778 NPI number — STACIA BETH BIRDSALL CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRDSALL
Provider First Name:
STACIA
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
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:
1174629778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 WALKER ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10013-4135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-226-8866
Provider Business Mailing Address Fax Number:
212-226-2289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
268 CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10013-3599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-966-0228
Provider Business Practice Location Address Fax Number:
212-966-9330
Provider Enumeration Date:
09/15/2006

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: 367A00000X , with the licence number:  F001385-1 , 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: 03338112 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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