Basic Information
| Provider Information | |||||||||
| NPI: | 1033145784 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHULTES | ||||||||
| FirstName: | PHILIP | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | ANESTHESIOLOGISTS OF GLENS FALLS | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054951357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007201664 | ||||||||
| FaxNumber: | 2077532020 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265127 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 209294 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01805554 | 05 | NY | MEDICAID |