1285763912 NPI number — CHAMPLAIN PAIN RELIEF AND NEUROLOGY, PLLC

Table of content: (NPI 1285763912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285763912 NPI number — CHAMPLAIN PAIN RELIEF AND NEUROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAMPLAIN PAIN RELIEF AND NEUROLOGY, PLLC
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:
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:
1285763912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 MARGARET STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
PLATTSBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-566-8603
Provider Business Mailing Address Fax Number:
518-566-8582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 MARGARET STREET
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-566-8603
Provider Business Practice Location Address Fax Number:
518-566-8582
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GAUGHAN
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
CELESTE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
518-566-8603

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  213308 , 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: 698338 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 130023170 . This is a "RRMCR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2033749 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010213308 . This is a "EXCELLUS BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000495471003 . This is a "BLUE SHIELD OF NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01998998 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110639300 . This is a "USDOL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 8C1231 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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