Basic Information
| Provider Information | |||||||||
| NPI: | 1093771677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME COLUMBIA GREENE MEDICAL ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 949 COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188287188 | ||||||||
| FaxNumber: | 5188285049 | ||||||||
| Practice Location | |||||||||
| Address1: | 949 COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188287188 | ||||||||
| FaxNumber: | 5188285049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | CLARENCE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5188287188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 123180 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207RG0100X | 109985 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 209006 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00195813 | 05 | NY | MEDICAID | 02311659 | 05 | NY | MEDICAID |