1679166284 NPI number — COLUMBIA MEMORIAL REGIONAL MEDICAL PLLC

Table of content: (NPI 1679166284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679166284 NPI number — COLUMBIA MEMORIAL REGIONAL MEDICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA MEMORIAL REGIONAL MEDICAL PLLC
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:
TANNERSVILLE FAMILY CARE
Provider Other Organization Name Type Code:
5
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:
1679166284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12534-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-697-3258
Provider Business Mailing Address Fax Number:
518-828-8183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6171 ROUTE 23A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TANNERSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-589-6843
Provider Business Practice Location Address Fax Number:
518-589-6844
Provider Enumeration Date:
02/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MAHONEY
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
518-828-8090

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03227290 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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