1669587879 NPI number — DR. MARC CHARLES JANIS MD

Table of content: MRS. LORA LYN LEAF OTR L (NPI 1558419838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669587879 NPI number — DR. MARC CHARLES JANIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANIS
Provider First Name:
MARC
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1669587879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 STEVENS AVE STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10550-2682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-664-7311
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 STEVENS AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10550-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-664-7311
Provider Business Practice Location Address Fax Number:
914-664-2530
Provider Enumeration Date:
08/20/2006

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: 208800000X , with the licence number:  171207 , 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: 1000017523 . This is a "AFFINITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: WS889 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4573899 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01475350 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2900116 . This is a "GHUBB" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6010835 . This is a "GHL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 79403 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 29430P . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 133870823 . This is a "POMCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 552931 . This is a "USHC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0D0068 . This is a "PHS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1147638 . This is a "UNITED" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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