1558312637 NPI number — DR. RALPH K. JACKSON M.D.

Table of content: (NPI 1417138843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558312637 NPI number — DR. RALPH K. JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
RALPH
Provider Middle Name:
K.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1558312637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10031-0601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-283-0333
Provider Business Mailing Address Fax Number:
212-234-4954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1727 AMSTERDAM AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10031-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-283-0333
Provider Business Practice Location Address Fax Number:
212-234-4954
Provider Enumeration Date:
05/13/2006

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: 207W00000X , with the licence number:  127939 , 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: 00524543 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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