1396874343 NPI number — DR. JEROME B GLASSMITH DPM

Table of content: DR. JEROME B GLASSMITH DPM (NPI 1396874343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396874343 NPI number — DR. JEROME B GLASSMITH DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASSMITH
Provider First Name:
JEROME
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1396874343
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:
4105 31ST AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASTORIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11103-3462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-278-8020
Provider Business Mailing Address Fax Number:
718-278-8599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4105 31ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11103-3462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-278-8020
Provider Business Practice Location Address Fax Number:
718-278-8599
Provider Enumeration Date:
03/05/2007

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: 213E00000X , with the licence number:  2400 , 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: 1101493690 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: ACCESS 931365 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P62577571 . This is a "MULTIPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 002400A39 . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 825983 . This is a "PENNSYLVANIA BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P030002400NY01 . This is a "ANTHEM 6450" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P463339 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 177233 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 24409 . This is a "VITRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 36528P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4809110772 . This is a "RR MCR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C4625 . This is a "PHS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1870 . This is a "MAGNAHEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: GJ2400 . This is a "ATLANTIS HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P27721 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0086040 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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