Basic Information
Provider Information | |||||||||
NPI: | 1134157605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHILDRESS | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100166402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2122633293 | ||||||||
FaxNumber: | 2122633522 | ||||||||
Practice Location | |||||||||
Address1: | 550 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100166402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2122633293 | ||||||||
FaxNumber: | 2122633522 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 03/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME95727 | FL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 35 123788 | OH | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207XX0005X | ME 95727 | FL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 2081S0010X | ME 95727 | FL | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | FL |   | MEDICAID | PENDING | 01 | FL | BLUE SHIELD OF FL | OTHER |