Basic Information
Provider Information | |||||||||
NPI: | 1538138615 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAX | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | ASA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 WEST 6TH STREET | ||||||||
Address2: |   | ||||||||
City: | OSWEGO | ||||||||
State: | NY | ||||||||
PostalCode: | 13126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189606159 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 74 BUNNER STREET | ||||||||
Address2: |   | ||||||||
City: | OSWEGO | ||||||||
State: | NY | ||||||||
PostalCode: | 13126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189606159 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 04/10/2015 | ||||||||
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 | 204C00000X | 156672-1 | NY | N |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |   | 2084P0800X | 156672-1 | NY | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 01822595 | 05 | NY |   | MEDICAID |