Basic Information
Provider Information | |||||||||
NPI: | 1548242290 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVANS | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | LAPP | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 IRONGATE CENTER | ||||||||
Address2: |   | ||||||||
City: | GLENS FALLS | ||||||||
State: | NY | ||||||||
PostalCode: | 128013471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187934409 | ||||||||
FaxNumber: | 5187935886 | ||||||||
Practice Location | |||||||||
Address1: | 3 IRONGATE CENTER | ||||||||
Address2: |   | ||||||||
City: | GLENS FALLS | ||||||||
State: | NY | ||||||||
PostalCode: | 128013471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187934409 | ||||||||
FaxNumber: | 5187935886 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 02/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 147106 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00811665 | 05 | NY |   | MEDICAID | 021200700360 | 01 | NY | FIDELIS | OTHER | 10471359 | 01 | NY | CAQH | OTHER | 10000596 | 01 | NY | CDPHP | OTHER | 00020846401 | 01 | NY | UNIVERA | OTHER | 77D831 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | CD1981 | 01 |   | RAILROAD MEDICARE GROUP # | OTHER | 000000056822 | 01 | NY | GHI-HMO | OTHER | 000401120002 | 01 | NY | BLUE SHIELD NENY | OTHER | 08169 | 01 | NY | MVP | OTHER |