1992077671 NPI number — COMMUNITY CARE PHYSICIANS, PC

Table of content: (NPI 1992077671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992077671 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:
1992077671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2016
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
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 104
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:
518-836-2428
Provider Business Practice Location Address Fax Number:
518-836-2413
Provider Enumeration Date:
01/27/2012

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: 2085R0202X , with the licence number:  157791 , 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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