Basic Information
Provider Information | |||||||||
NPI: | 1952427924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLLINGSWORTH | ||||||||
FirstName: | CHARLIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 WEST 4TH STREET | ||||||||
Address2: | MOUNT VERNON NEIGHBORHOOD HEALTH CENTER | ||||||||
City: | MOUNT VERNON | ||||||||
State: | NY | ||||||||
PostalCode: | 10550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146997200 | ||||||||
FaxNumber: | 9146990837 | ||||||||
Practice Location | |||||||||
Address1: | 107 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MT VERNON | ||||||||
State: | NY | ||||||||
PostalCode: | 105504002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9146997200 | ||||||||
FaxNumber: | 9146990837 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2007 | ||||||||
LastUpdateDate: | 12/13/2011 | ||||||||
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 | 363AM0700X | 000368 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 000368 | 01 | NY | N.Y.S. LICENSE NUMBER | OTHER |