Basic Information
| Provider Information | |||||||||
| NPI: | 1902807407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEINRAUB | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 CAYUGA PARK RD | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075926603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 318 S ALBANY ST | ||||||||
| Address2: | BEECHTREE CARE CENTER | ||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148505406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072734166 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 170781 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01831149 | 05 | NY | MEDICAID |