1528288511 NPI number — ELLEN WEYBRIGHT BEALS OTR

Table of content: ELLEN WEYBRIGHT BEALS OTR (NPI 1528288511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528288511 NPI number — ELLEN WEYBRIGHT BEALS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEALS
Provider First Name:
ELLEN
Provider Middle Name:
WEYBRIGHT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEYBRIGHT
Provider Other First Name:
NANCY
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528288511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11471
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12211-0471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-877-4970
Provider Business Mailing Address Fax Number:
866-415-1258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
626 WATERVLIET SHAKER RD
Provider Second Line Business Practice Location Address:
SUITE 71
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-3618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-877-4970
Provider Business Practice Location Address Fax Number:
866-415-1258
Provider Enumeration Date:
05/01/2007

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: 225X00000X , with the licence number:  007564 , 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: 02871630 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007564 . This is a "NYS LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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