Basic Information
| Provider Information | |||||||||
| NPI: | 1861750010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROME MEDICAL PRACTICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DR. GLADY JACOB MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 HILL RD | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134414203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153370429 | ||||||||
| FaxNumber: | 3153560583 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 HILL RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134414203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153567380 | ||||||||
| FaxNumber: | 3153567386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | SALTZGABER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3153387232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROME MEDICAL PRACTICE | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 003788-1 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 003788-1 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 02735037 | 05 | NY | MEDICAID |