1194788372 NPI number — MICHAEL A DOLLARD PA

Table of content: MICHAEL A DOLLARD PA (NPI 1194788372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194788372 NPI number — MICHAEL A DOLLARD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOLLARD
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194788372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHENECTADY RD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-782-3700
Provider Business Mailing Address Fax Number:
518-782-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1240 NEW SCOTLAND RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SLINGERLANDS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12159-9222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-439-2460
Provider Business Practice Location Address Fax Number:
518-439-3025
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  006652 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080925000085 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6019908 . This is a "MVP HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10040637 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000495200004 . This is a "BSNENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03027016 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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