Basic Information
Provider Information | |||||||||
NPI: | 1831185222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHWARTZ | ||||||||
FirstName: | JERROLD | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 346 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137902558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077638008 | ||||||||
FaxNumber: | 6077638019 | ||||||||
Practice Location | |||||||||
Address1: | 507 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 137901810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077638008 | ||||||||
FaxNumber: | 6077638019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2005 | ||||||||
LastUpdateDate: | 02/06/2013 | ||||||||
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 | 207RA0401X | 165144 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207RG0300X | 165144 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 02313495 | 05 | NY |   | MEDICAID |