Basic Information
Provider Information | |||||||||
NPI: | 1790808095 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEI | ||||||||
FirstName: | JOHNNY | ||||||||
MiddleName: | Y | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072712050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 600 ROE AVE | ||||||||
Address2: | HOSPITALIST DEPARTMENT | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149051629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077377770 | ||||||||
FaxNumber: | 6072713686 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2007 | ||||||||
LastUpdateDate: | 02/18/2017 | ||||||||
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 | 207R00000X | MD00047863 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 48232 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 048232 | CT | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 252143 | NY | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 04586527 | 05 | NY |   | MEDICAID | 8508137 | 05 | WA |   | MEDICAID | 5149ME | 01 | WA | BLUE SHIELD # VM | OTHER |