Basic Information
| Provider Information | |||||||||
| NPI: | 1407956519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CARE PHYSICIANS, PC | ||||||||
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| OtherOrganizationName: | CAPITAL DISTRICT OB/GYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ELM AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | DELMAR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120543702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184399363 | ||||||||
| FaxNumber: | 5184394018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | STAMAS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5187823742 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 184827 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01450619 | 05 | NY | MEDICAID |