Basic Information
| Provider Information | |||||||||
| NPI: | 1508868415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRIQUES | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 ATRIUM DR | ||||||||
| Address2: | SUITE 100, ATTN: TAMMY M. BUTTON | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122051441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184352740 | ||||||||
| FaxNumber: | 5184582610 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 S MANNING BLVD | ||||||||
| Address2: | 6 CUSACK | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122081707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185258600 | ||||||||
| FaxNumber: | 5185256891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 231783 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 231783 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02529371 | 05 | NY | MEDICAID |