1619041100 NPI number — SHARON RUTH POLOVINA

Table of content: SHARON RUTH POLOVINA (NPI 1619041100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619041100 NPI number — SHARON RUTH POLOVINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLOVINA
Provider First Name:
SHARON
Provider Middle Name:
RUTH
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:
1619041100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1707 CENTRAL AVE
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:
12205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-464-0232
Provider Business Mailing Address Fax Number:
518-464-0202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-464-0232
Provider Business Practice Location Address Fax Number:
518-464-0202
Provider Enumeration Date:
11/17/2006

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: 1041C0700X , with the licence number:  R061709 , 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: 000402874001 . This is a "BLUESHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7350172 . This is a "EMPIEPPN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 550 146 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 051028000018 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: N36E41 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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