Basic Information
| Provider Information | |||||||||
| NPI: | 1407809924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINTON | ||||||||
| FirstName: | H LOUIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 PROSPECT AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188282566 | ||||||||
| FaxNumber: | 5186973403 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 PROSPECT AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188282566 | ||||||||
| FaxNumber: | 5186973403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 1-163259 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 040426007295 | 01 | FIDELIS | OTHER | 600461 | 01 | UNITED HEALTHCARE | OTHER | 000406283001 | 01 | BS OF NENY | OTHER | 0036315 | 01 | GHI PPO | OTHER | 105180 | 01 | WELLCARE | OTHER | 5180 | 01 | GHI HMO | OTHER | 01094820 | 05 | NY | MEDICAID | 10000352 | 01 | CDPHP | OTHER | 320532 | 01 | MVP | OTHER | 717002 | 01 | BC/BS | OTHER | P902860 | 01 | OXFORD | OTHER |