Basic Information
Provider Information | |||||||||
NPI: | 1669473583 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOHAWK VALLEY UROLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1703 GENESEE ST | ||||||||
Address2: |   | ||||||||
City: | UTICA | ||||||||
State: | NY | ||||||||
PostalCode: | 135015613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157241012 | ||||||||
FaxNumber: | 3157245219 | ||||||||
Practice Location | |||||||||
Address1: | 1703 GENESEE ST | ||||||||
Address2: |   | ||||||||
City: | UTICA | ||||||||
State: | NY | ||||||||
PostalCode: | 135015613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157241012 | ||||||||
FaxNumber: | 3157245219 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAYE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | I | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3157241012 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 48271 | 01 |   | GHI | OTHER | 245112 | 01 |   | MVP | OTHER | 245131 | 01 |   | MVP | OTHER | 368817 | 01 |   | MVP | OTHER |