1730218074 NPI number — FACIAL PLASTIC, RECONSTRUCTIVE & LASER SURGERY, PLLC

Table of content: (NPI 1730218074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730218074 NPI number — FACIAL PLASTIC, RECONSTRUCTIVE & LASER SURGERY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FACIAL PLASTIC, RECONSTRUCTIVE & LASER SURGERY, 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:
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:
1730218074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 N WATER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12601-1721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-454-8025
Provider Business Mailing Address Fax Number:
845-454-8026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
82 N WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12601-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-454-8025
Provider Business Practice Location Address Fax Number:
845-454-8026
Provider Enumeration Date:
03/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ABRAHAM
Authorized Official First Name:
MANOJ
Authorized Official Middle Name:
TIMOTHY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
845-454-8025

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  211519 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YS0123X , with the licence number: 211519 , 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: 7539468 . This is a "AETNA PPO POS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000415207001 . This is a "HEALTHNOW" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10074336 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 363203 . This is a "MVP PLASTIC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3063915 . This is a "OXFORD LIBERTY, FREEDOM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3289877 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 362957 . This is a "MVP ENT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7M7521 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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