Provider Demographics
NPI:1154138352
Name:DEARIE PREVENTATIVE MEDICINE PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DEARIE PREVENTATIVE MEDICINE PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-737-3508
Mailing Address - Street 1:PO BOX 7241
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98417-0241
Mailing Address - Country:US
Mailing Address - Phone:206-486-2053
Mailing Address - Fax:
Practice Address - Street 1:418 BROADWAY STE N
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-2922
Practice Address - Country:US
Practice Address - Phone:206-486-2053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-12
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center