1790979417 NPI number — ITHACA DERMATOLOGY PLLC

Table of content: (NPI 1790979417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790979417 NPI number — ITHACA DERMATOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ITHACA DERMATOLOGY 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:
1790979417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 TAUGHANNOCK BLVD
Provider Second Line Business Mailing Address:
PO BOX 366
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-277-4035
Provider Business Mailing Address Fax Number:
607-277-3888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 CLIFF STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-256-7546
Provider Business Practice Location Address Fax Number:
607-256-0049
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SILVERS
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
607-256-7546

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  220803 , 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)





Copyright © 2007-2025 www.npivalidator.com