Provider Demographics
NPI:1679559652
Name:ANSELL, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:ANSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E 77TH ST
Mailing Address - Street 2:DEPT OF MEDICINE, 6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1850
Mailing Address - Country:US
Mailing Address - Phone:212-434-2142
Mailing Address - Fax:212-434-2246
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:DEPT OF MEDICINE, 6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2142
Practice Address - Fax:212-434-2246
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA36584207RH0000X
NY249338207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2016648Medicaid
NY03022364Medicaid
MAC05068Medicare PIN
MAA38604Medicare UPIN
MAUX7424Medicare PIN