Provider Demographics
NPI:1770552531
Name:BARTHOLOMEW, JEREMY L (DC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:BARTHOLOMEW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-0315
Mailing Address - Country:US
Mailing Address - Phone:315-841-3010
Mailing Address - Fax:315-841-3020
Practice Address - Street 1:124 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:NY
Practice Address - Zip Code:13480-1108
Practice Address - Country:US
Practice Address - Phone:315-841-3010
Practice Address - Fax:315-841-3020
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010937111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02644071Medicaid
NYBA0438Medicare ID - Type UnspecifiedMEDICARE GROUP
NYU94734Medicare UPIN
NYRA5651Medicare PIN