=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922128628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELMER F PLANTZ JR. NNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W 6TH ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-349-5572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1064 COUNTY ROUTE 22 PO BOX 435
-----------------------------------------------------
City | ALTMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13302-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-298-7728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LN0000X
-----------------------------------------------------
Taxonomy Name | Neonatal Nurse Practitioner
-----------------------------------------------------
License Number | F350092-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------