1548219728 NPI number — MS. FAYE MEMOLO PA-C

Table of content: MS. FAYE MEMOLO PA-C (NPI 1548219728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548219728 NPI number — MS. FAYE MEMOLO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEMOLO
Provider First Name:
FAYE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1548219728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
187 MAIN ST., APT. 6
Provider Second Line Business Mailing Address:
NATIONAL DERMATOLOGY HEALTHCARE/FAYE MEMOLO, PA-C
Provider Business Mailing Address City Name:
COLEBROOK
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-348-0259
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187 MAIN ST
Provider Second Line Business Practice Location Address:
APT. 6
Provider Business Practice Location Address City Name:
COLEBROOK
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03576-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-348-0259
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2006

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: 363A00000X , with the licence number:  0403 P , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200999212 . This is a "TAX ID" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 7058699 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 00068486 . This is a "BCBS OF VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 30333351 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000213 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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