Provider Demographics
NPI:1043275969
Name:OPTUM INFUSION SERVICES 100, INC.
Entity type:Organization
Organization Name:OPTUM INFUSION SERVICES 100, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:499-988-5893
Mailing Address - Street 1:931 D CONKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735
Mailing Address - Country:US
Mailing Address - Phone:800-346-6348
Mailing Address - Fax:866-689-3569
Practice Address - Street 1:931 D CONKLIN STREET
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735
Practice Address - Country:US
Practice Address - Phone:800-346-6348
Practice Address - Fax:866-689-3569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9296L0001251F00000X
NY020477332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY85329OtherMVP
NYANC1772OtherOXFORD
NY9296L001OtherHOME CARE SERVICE AGENCY LICENSE
NY58658OtherVYTRA
NYB6A532OtherEMPIRE BC/BS
NY114382OtherAETNA