Basic Information
Provider Information | |||||||||
NPI: | 1114018140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCANTLEBURY | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | ANTOINETTE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 CENTRAL PARK W | ||||||||
Address2: | SUITE 1C | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100256547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127496010 | ||||||||
FaxNumber: | 2127496011 | ||||||||
Practice Location | |||||||||
Address1: | 350 CENTRAL PARK W | ||||||||
Address2: | SUITE 1C | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100256547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2127496010 | ||||||||
FaxNumber: | 2127496011 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 11/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 208050 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 01807414 | 05 | NY |   | MEDICAID |