1629774922 NPI number — BOLTROPE PODIATRY NY PLLC

Table of content: (NPI 1629774922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629774922 NPI number — BOLTROPE PODIATRY NY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLTROPE PODIATRY NY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1629774922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
74 PASCACK RD STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARK RIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07656-1942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-571-0214
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NANUET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10954-2884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-777-1430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2023

Additional Information

Authorized Official

Authorized Official Last Name:
GEWIRTZ
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
201-391-1113

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07680188 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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