Basic Information
| Provider Information | |||||||||
| NPI: | 1154757102 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SARATOGA HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY PRACTICE AT MALTA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1368 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122011368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183481276 | ||||||||
| FaxNumber: | 5183481279 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120205061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182892718 | ||||||||
| FaxNumber: | 5185838797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 01/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5185838497 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SARATOGA HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.