Basic Information
Provider Information | |||||||||
NPI: | 1285603548 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUDWIG | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 95 E CHAUTAUQUA ST | ||||||||
Address2: | PO BOX 168 | ||||||||
City: | MAYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 147570168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7167537107 | ||||||||
FaxNumber: | 7167537980 | ||||||||
Practice Location | |||||||||
Address1: | 95 E CHAUTAUQUA ST | ||||||||
Address2: |   | ||||||||
City: | MAYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 147570168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7167537107 | ||||||||
FaxNumber: | 7167537980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2006 | ||||||||
LastUpdateDate: | 02/29/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008778 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 000570381005 | 01 | NY | BCBSWNY | OTHER | 00026521702 | 01 | NY | UNIVERA | OTHER | 02311080 | 05 | NY |   | MEDICAID | 9512115 | 01 | NY | INDEPENDENT HEALTH | OTHER |