1760408330 NPI number — CAROL MIYAKE M.D.

Table of content: CAROL MIYAKE M.D. (NPI 1760408330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760408330 NPI number — CAROL MIYAKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIYAKE
Provider First Name:
CAROL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1760408330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
243 NORTH ROAD, SUITE 304
Provider Second Line Business Mailing Address:
PREMIER MEDICAL GROUP OF THE HUDSON VALLEY, P.C.
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12601-1364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-471-9410
Provider Business Mailing Address Fax Number:
845-451-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WEBSTER AVE STE 301
Provider Second Line Business Practice Location Address:
NEW CENTURY MEDICAL ASSOCIATES
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12601-1364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-790-6100
Provider Business Practice Location Address Fax Number:
845-345-9966
Provider Enumeration Date:
07/15/2006

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: 207RE0101X , with the licence number:  1712931 , 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: 01800802 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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