1609856103 NPI number — SHERYL L TRASK PT

Table of content: SHERYL L TRASK PT (NPI 1609856103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609856103 NPI number — SHERYL L TRASK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRASK
Provider First Name:
SHERYL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1609856103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5480 LAKE RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14420-9754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-637-8305
Provider Business Mailing Address Fax Number:
585-637-9117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5480 LAKE RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROCKPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14420-9754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-637-8305
Provider Business Practice Location Address Fax Number:
585-637-9117
Provider Enumeration Date:
01/19/2006

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: 225100000X , with the licence number:  010728-1 , 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: 01949724 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: FA0525 . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6699699 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P010010728 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 820882 . This is a "EMPIRE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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