Basic Information
| Provider Information | |||||||||
| NPI: | 1649544750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPSTATE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 EMMA LN | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120653763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183834198 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 EMMA LN | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120653763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183834198 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | TROITINO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5183834198 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 122852 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.