Basic Information
| Provider Information | |||||||||
| NPI: | 1548313745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTESMAN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 BROAD STREET PLZ | ||||||||
| Address2: | ADIRONDACK MEDICAL SERVICES | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266992 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 PARK ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187981719 | ||||||||
| FaxNumber: | 5187981943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 110911-1 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00368621 | 05 | NY | MEDICAID |