1902542913 NPI number — PHEDRE PHARA PAULEMON

Table of content: (NPI 1902542913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902542913 NPI number — PHEDRE PHARA PAULEMON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHEDRE PHARA PAULEMON
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:
6
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:
1902542913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 NOSTRAND AVE APT 2C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11210-4715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-907-0797
Provider Business Mailing Address Fax Number:
917-933-4212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 LINDEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11203-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-907-0797
Provider Business Practice Location Address Fax Number:
917-933-4212
Provider Enumeration Date:
05/11/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PAULEMON
Authorized Official First Name:
PHEDRE
Authorized Official Middle Name:
PHARA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
917-907-0797

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: F343011-C1D . This is a "HEALTHFIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 05401478 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 798935 . This is a "CIGA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 835995 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P0569292 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 241008000231 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3886122 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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