Healthcare Provider Details

I. General information

NPI: 1902807407
Provider Name (Legal Business Name): JENNIFER WEINRAUB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 S ALBANY ST BEECHTREE CARE CENTER
ITHACA NY
14850-5406
US

IV. Provider business mailing address

121 CAYUGA PARK RD
ITHACA NY
14850-1405
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-4166
  • Fax:
Mailing address:
  • Phone: 607-592-6603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number170781
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: