Basic Information
Provider Information | |||||||||
NPI: | 1790773745 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAHNER | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | ANDREW | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 85 SOUTH WEST STREET | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | NY | ||||||||
PostalCode: | 13077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077533797 | ||||||||
FaxNumber: | 6077536677 | ||||||||
Practice Location | |||||||||
Address1: | 20 EAST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | MARATHON | ||||||||
State: | NY | ||||||||
PostalCode: | 13803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6078493271 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2005 | ||||||||
LastUpdateDate: | 05/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 189310 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 02673729 | 05 | NY |   | MEDICAID |