Basic Information
| Provider Information | |||||||||
| NPI: | 1396759767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REALI | ||||||||
| FirstName: | DEAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 304 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128010304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265918 | ||||||||
| FaxNumber: | 5189265917 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | GLENS FALLS HOSPITAL | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265918 | ||||||||
| FaxNumber: | 5189265917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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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 | 207R00000X | 202668 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 202668 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | P00960207 | 01 | NY | RR MEDICARE | OTHER | 01706578 | 05 | NY | MEDICAID |