1184676322 NPI number — THERESA M DOMAGOLA ACNP C

Table of content: THERESA M DOMAGOLA ACNP C (NPI 1184676322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184676322 NPI number — THERESA M DOMAGOLA ACNP C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMAGOLA
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP C
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:
1184676322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2365 S CLINTON AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14618-2663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-442-5320
Provider Business Mailing Address Fax Number:
585-442-5526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CANAL LANDING BLVD
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14626-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-239-7300
Provider Business Practice Location Address Fax Number:
585-227-7723
Provider Enumeration Date:
05/16/2006

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: 363LA2100X , with the licence number:  430210 , 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: 02601196 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70008ARA6884 . This is a "MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 104847400 . 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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