Basic Information
| Provider Information | |||||||||
| NPI: | 1447206495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY NEUROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91 | ||||||||
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| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157824207 | ||||||||
| FaxNumber: | 3157828699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829003 | ||||||||
| FaxNumber: | 3157829010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | LATIF | ||||||||
| AuthorizedOfficialFirstName: | ABDUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3157829003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.