Provider Demographics
NPI:1104245299
Name:BURROUGHS, NOAH
Entity type:Individual
Prefix:MR
First Name:NOAH
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 WESTERVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510
Mailing Address - Country:US
Mailing Address - Phone:646-359-7911
Mailing Address - Fax:
Practice Address - Street 1:1842 WESTERVELT AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2228
Practice Address - Country:US
Practice Address - Phone:646-359-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337436234171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12334354Medicaid