1679641617 NPI number — MARK JOHN VANHUSEN MD

Table of content: MARK JOHN VANHUSEN MD (NPI 1679641617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679641617 NPI number — MARK JOHN VANHUSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANHUSEN
Provider First Name:
MARK
Provider Middle Name:
JOHN
Provider Name Prefix Text:
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:
1679641617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8100 OSWEGO ROAD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
LIVERPOOL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-652-6551
Provider Business Mailing Address Fax Number:
315-652-9698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8100 OSWEGO ROAD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
LIVERPOOL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-652-6551
Provider Business Practice Location Address Fax Number:
315-652-9698
Provider Enumeration Date:
11/30/2006

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: 207Q00000X , with the licence number:  183680 , 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: 085000 . This is a "MVP HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01227063 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080178303 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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