1457626129 NPI number — ANTHONY L. JORDAN HEALTH CORPORATION

Table of content: (NPI 1457626129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457626129 NPI number — ANTHONY L. JORDAN HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY L. JORDAN HEALTH CORPORATION
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:
6
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:
1457626129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 HOLLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14605-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-423-5800
Provider Business Mailing Address Fax Number:
585-423-2860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 SAINT PAUL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-325-5232
Provider Business Practice Location Address Fax Number:
585-546-3485
Provider Enumeration Date:
03/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARBIN
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
585-423-2878

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  2701211R , 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: 16467A . This is a "MEDICARE PART B" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6613 . This is a "BLUE CROSS OF ROCHESTER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00384969 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331838 . This is a "MEDICARE PART A" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: G0187295590 . This is a "BLUE CHOICE OF ROCHESTER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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