Basic Information
| Provider Information | |||||||||
| NPI: | 1104085851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUSSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754133 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | MAB-GPCC | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754133 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2008 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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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 | 208800000X | 251814 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1104085851 | 01 | NY | MVP HEALTHCARE | OTHER | 03382616 | 05 | NY | MEDICAID | 200230284 | 01 | NY | CDPHP | OTHER |