1003358920 NPI number — COMMUNITY CARE PHYSICIANS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003358920 NPI number — COMMUNITY CARE PHYSICIANS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE PHYSICIANS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE AUDIOLOGY CENTER AT COMMUNITY CARE PHYSICIANS - CLIFTON PARK
Provider Other Organization Name Type Code:
3
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:
1003358920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHCTDY RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2442
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:
1783 ROUTE 9
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
HALFMOON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-783-3110
Provider Business Practice Location Address Fax Number:
518-640-6756
Provider Enumeration Date:
11/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
STAMAS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SENIOR CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
518-782-3742

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  001103 , 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)





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