1073760385 NPI number — COMMUNITY CARE PHYSICIANS, PC

Table of content: (NPI 1073760385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073760385 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:
Provider Other Organization Name Type Code:
6
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:
1073760385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2019
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:
3757 CARMAN RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GUILDERLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-881-1188
Provider Business Practice Location Address Fax Number:
518-881-1192
Provider Enumeration Date:
08/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COONS
Authorized Official First Name:
DEBBY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
518-213-0478

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  176417 , 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: 01322398 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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