Provider Demographics
NPI:1417994716
Name:WIDELL, JARED MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:WIDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:GUTHRIE CORTLAND MEDICAL CENTER
Practice Address - Street 2:134 HOMER AVENUE
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-756-3561
Practice Address - Fax:607-756-3562
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176591207RC0000X
DCMD034608207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035391600Medicaid
VA010039991Medicaid
MD403555100Medicaid
VA010039991Medicaid
DCP00117796Medicare ID - Type UnspecifiedRAILROAD
DC013325W34Medicare ID - Type Unspecified
MD403555100Medicaid
DC013325YTFMedicare PIN