1689164584 NPI number — NORTHEAST FOOT CARE PODIATRY PC

Table of content: (NPI 1689164584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689164584 NPI number — NORTHEAST FOOT CARE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST FOOT CARE PODIATRY PC
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:
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:
1689164584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 SEMINARA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARNERVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10923-1736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-641-4783
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 SEMINARA CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNERVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-641-4783
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MONTALVO
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
845-641-4783

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  N006820 , 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: A400176602 . This is a "MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 04816428 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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