Healthcare Provider Details

I. General information

NPI: 1124224100
Provider Name (Legal Business Name): JEREMY NIELSEN RICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BAACH, 121 CSH OTOLARYNGOLOGY SECTION
APO AP
96205
US

IV. Provider business mailing address

UNIT 15244 BOX 783
APO AP
96205-5244
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1285
  • Fax:
Mailing address:
  • Phone: 315-737-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101245147
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: