1265433593 NPI number — NORTHERN NY INFUSION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265433593 NPI number — NORTHERN NY INFUSION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN NY INFUSION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTIONCARE
Provider Other Organization Name Type Code:
3
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:
1265433593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18564 US ROUTE 11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13601-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-785-5436
Provider Business Mailing Address Fax Number:
315-786-3497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18564 US ROUTE 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-785-5436
Provider Business Practice Location Address Fax Number:
315-786-3497
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
OFFICE/BILLING MANAGER
Authorized Official Telephone Number:
315-785-5436

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  9957L001 , 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: 01776109 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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