1497740781 NPI number — DR. MICHELLE CECELIA JARDINE MD

Table of content: DR. MICHELLE CECELIA JARDINE MD (NPI 1497740781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497740781 NPI number — DR. MICHELLE CECELIA JARDINE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JARDINE
Provider First Name:
MICHELLE
Provider Middle Name:
CECELIA
Provider Name Prefix Text:
DR.
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:
1497740781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 DEER PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BABYLON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11702-2313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-941-1000
Provider Business Mailing Address Fax Number:
631-941-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 HALLOCK RD
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11790-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-941-1000
Provider Business Practice Location Address Fax Number:
631-941-1010
Provider Enumeration Date:
09/13/2005

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: 207RE0101X , with the licence number:  207582 , 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)





Copyright © 2007-2025 www.npivalidator.com