Basic Information
| Provider Information | |||||||||
| NPI: | 1043358815 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID- HUDSON MEDICAL GROUP P C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 600 WESTAGE BUSINESS CTR DR | ||||||||
| Address2: | |||||||||
| City: | FISHKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125242281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452315600 | ||||||||
| FaxNumber: | 8452315489 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 WESTAGE BUSINESS CTR DR | ||||||||
| Address2: | |||||||||
| City: | FISHKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125242281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452315560 | ||||||||
| FaxNumber: | 8452315489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARVEY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT & CHAIRMAN OF THE BD | ||||||||
| AuthorizedOfficialTelephone: | 8452315600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02993768 | 05 | NY | MEDICAID | C24343 | 01 | NY | MEDICARE RR PTAN | OTHER |