1457550352 NPI number — WAINWRIGHT DERMATOLOGY, PLLC

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 1457550352 NPI number — WAINWRIGHT DERMATOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAINWRIGHT DERMATOLOGY, 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:
1457550352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROSS RIVER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10518-0365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-763-3000
Provider Business Mailing Address Fax Number:
718-518-8616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 NORTH SALEM ROAD
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
CROSS RIVER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10518-0365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-763-3000
Provider Business Practice Location Address Fax Number:
718-518-8616
Provider Enumeration Date:
07/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WAINWRIGHT
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRICIPAL PHYSICIAN - ONE MEMBER LLC
Authorized Official Telephone Number:
914-763-3000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  234018 , 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: 1598737462 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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