1922521616 NPI number — JENNIFER J GRANATO NP

Table of content: JENNIFER J GRANATO NP (NPI 1922521616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922521616 NPI number — JENNIFER J GRANATO NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANATO
Provider First Name:
JENNIFER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1922521616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEDICAL PAIN MANAGEMENT SERVICES, PLLC
Provider Second Line Business Mailing Address:
116 EVERETT ROAD
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12205-1427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-463-0171
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 SOUTHWOODS BLVD # PC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12211-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-292-6000
Provider Business Practice Location Address Fax Number:
518-292-6050
Provider Enumeration Date:
07/25/2017

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: 363L00000X , with the licence number:  F341968 , 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: 04844684 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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