1194782425 NPI number — LORAINE IPPOLITO NP

Table of content: LORAINE IPPOLITO NP (NPI 1194782425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194782425 NPI number — LORAINE IPPOLITO NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IPPOLITO
Provider First Name:
LORAINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1194782425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3675 SOUTHWESTERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-1732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-972-0279
Provider Business Mailing Address Fax Number:
716-972-0271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3675 SOUTHWESTERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-1732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-972-0279
Provider Business Practice Location Address Fax Number:
716-972-0271
Provider Enumeration Date:
04/28/2006

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: 363LA2200X , with the licence number:  F3002671 , 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: 00021054903 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426002812 . This is a "FIDELIS CARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9513162 . This is a "IHA #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02794365 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00021054902 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 180048BJ . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000560087008 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000560087007 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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