Basic Information
Provider Information | |||||||||
NPI: | 1356375240 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALBANY MEDICAL COLLEGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALBANY MEDICAL COLLEGE CANCER CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 618 CENTRAL AVE | ||||||||
Address2: | MC 106 | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122061916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182629702 | ||||||||
FaxNumber: | 5182629707 | ||||||||
Practice Location | |||||||||
Address1: | 47 NEW SCOTLAND AVE | ||||||||
Address2: | MC 57 | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122083412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182625376 | ||||||||
FaxNumber: | 5182625304 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VERDILE | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | DEAN | ||||||||
AuthorizedOfficialTelephone: | 5182623773 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 363A00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 01520676 | 05 | NY |   | MEDICAID | 01226920 | 05 | NY |   | MEDICAID | 1006966 | 05 | VT |   | MEDICAID | 9766804 | 05 | MA |   | MEDICAID |