1568926434 NPI number — JEANNIE L WILLIAMS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568926434 NPI number — JEANNIE L WILLIAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
JEANNIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1568926434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
85 S WEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13077-1542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-753-3797
Provider Business Mailing Address Fax Number:
607-753-6677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2805 CINCINNATUS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATUS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13040-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-863-4126
Provider Business Practice Location Address Fax Number:
607-758-3019
Provider Enumeration Date:
01/25/2019

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: 363LF0000X , with the licence number:  343992 , 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: 05561739 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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