Basic Information
Provider Information | |||||||||
NPI: | 1942295183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHIN | ||||||||
FirstName: | WARREN | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
Address2: | FL 2 | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072712050 | ||||||||
FaxNumber: | 6072712099 | ||||||||
Practice Location | |||||||||
Address1: | 1138 BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149042502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077347982 | ||||||||
FaxNumber: | 6077341953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2005 | ||||||||
LastUpdateDate: | 11/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS5417 | FL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 13703 | NH | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 163367 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 05936847 | 05 | NY |   | MEDICAID | 048243900 | 05 | FL |   | MEDICAID |