1528161817 NPI number — DR. DERMOT CONNOLE JINKS D.C.

Table of content: (NPI 1194551010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528161817 NPI number — DR. DERMOT CONNOLE JINKS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JINKS
Provider First Name:
DERMOT
Provider Middle Name:
CONNOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1528161817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 ROWLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLSTON SPA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-2684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-363-0202
Provider Business Mailing Address Fax Number:
518-363-0711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 CENTRAL ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960-4375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-531-0202
Provider Business Practice Location Address Fax Number:
978-532-7076
Provider Enumeration Date:
09/05/2006

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: 193400000X , with the licence number:  X011848 , 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: Y36302 . This is a "BLUE CROSS BLUE SHIELD #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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