Basic Information
| Provider Information | |||||||||
| NPI: | 1114059185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKLOUCICH | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 276-280 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077222769 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 276-280 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077222769 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 252865 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03113559 | 05 | NY | MEDICAID |