1487711438 NPI number — PHOEBE L EVERSON MD

Table of content: PHOEBE L EVERSON MD (NPI 1487711438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487711438 NPI number — PHOEBE L EVERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERSON
Provider First Name:
PHOEBE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1487711438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2868
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLATTSBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12901-0259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-562-7900
Provider Business Mailing Address Fax Number:
518-562-7933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 BEEKMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-561-2000
Provider Business Practice Location Address Fax Number:
518-561-0881
Provider Enumeration Date:
01/02/2007

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: 207P00000X , with the licence number:  157114 , 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: 000490094001 . This is a "BSNENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 114406 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 90031 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: PE01760N10 . This is a "EMPIRE BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01936589 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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