Basic Information
| Provider Information | |||||||||
| NPI: | 1144215161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID HUDSON PLASTIC SURGERY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 MARYS AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453380789 | ||||||||
| FaxNumber: | 8453349150 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 MARYS AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453380789 | ||||||||
| FaxNumber: | 8453349150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/10/2008 | ||||||||
| NPIReactivationDate: | 03/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | HAGERTY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | GROUP OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8453380799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 2017201 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.