1518930809 NPI number — JEFFREY W HATHAWAY PT, DPT

Table of content: JEFFREY W HATHAWAY PT, DPT (NPI 1518930809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518930809 NPI number — JEFFREY W HATHAWAY PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATHAWAY
Provider First Name:
JEFFREY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1518930809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
792 N MAIN ST
Provider Second Line Business Mailing Address:
STE 100C
Provider Business Mailing Address City Name:
NORTH SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13212-1644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-458-2552
Provider Business Mailing Address Fax Number:
315-458-2575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
792 N MAIN ST
Provider Second Line Business Practice Location Address:
STE 100C
Provider Business Practice Location Address City Name:
NORTH SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13212-1644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-458-2552
Provider Business Practice Location Address Fax Number:
315-458-2575
Provider Enumeration Date:
02/08/2006

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: 225100000X , with the licence number:  008280 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT017496 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 10927 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00004725 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 435663 . This is a "MVP HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000013512 . This is a "BCBS CNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 068AX . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 918237001 . This is a "HEALTHNOW NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P00404780 . This is a "RAILROAD MEDICARE SRRGA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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