1114340510 NPI number — UPSTATE PHYSICIAN SERVICES, PC

Table of content: (NPI 1114340510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114340510 NPI number — UPSTATE PHYSICIAN SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE PHYSICIAN SERVICES, 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:
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:
1114340510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 162
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELMAR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12054-0162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-687-1960
Provider Business Mailing Address Fax Number:
518-687-1970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-3482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-687-1960
Provider Business Practice Location Address Fax Number:
518-687-1970
Provider Enumeration Date:
01/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MEGHANI
Authorized Official First Name:
MUSTAFAIN
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
518-687-1960

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 171212063 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 03925651 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04646599 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com