1396777454 NPI number — MR. EDWARD D SOREL PHD

Table of content: MR. EDWARD D SOREL PHD (NPI 1396777454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396777454 NPI number — MR. EDWARD D SOREL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOREL
Provider First Name:
EDWARD
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

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:
1396777454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 N CAYGUA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-273-1038
Provider Business Mailing Address Fax Number:
607-256-8363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 N CAYGUA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-273-1038
Provider Business Practice Location Address Fax Number:
607-256-8363
Provider Enumeration Date:
07/07/2006

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: 103TC0700X , with the licence number:  06772 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TH0100X , with the licence number: 06772 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SO67728B . This is a "WORKMENS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1P323680 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".




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