1972500205 NPI number — DR. ANDREW JON CHERNACK M.D.

Table of content: DR. ANDREW JON CHERNACK M.D. (NPI 1972500205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972500205 NPI number — DR. ANDREW JON CHERNACK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHERNACK
Provider First Name:
ANDREW
Provider Middle Name:
JON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1972500205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
04/05/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
243 NORTH RD
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12601-1172
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
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12601-1361
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:
07/01/2005

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: 207Q00000X , with the licence number:  154432 , 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: 01288040 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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