Basic Information
| Provider Information | |||||||||
| NPI: | 1689851115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY PRIMARY MEDICAL CARE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 RADIO AVE | ||||||||
| Address2: | |||||||||
| City: | MILLER PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117643125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318218911 | ||||||||
| FaxNumber: | 6318218912 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 RADIO AVE | ||||||||
| Address2: | |||||||||
| City: | MILLER PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117643125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318218911 | ||||||||
| FaxNumber: | 6318218912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | DHILLON | ||||||||
| AuthorizedOfficialFirstName: | JAGPREET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6318218911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 210655 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 210655 | 01 | NY | NYS LICENSE | OTHER |