Basic Information
| Provider Information | |||||||||
| NPI: | 1700180684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAMPLAIN VALLEY PATHOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 309 | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129010309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185627128 | ||||||||
| FaxNumber: | 5185616325 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 BEEKMAN ST | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129011438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185627128 | ||||||||
| FaxNumber: | 5185616325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | GORMAN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5185627128 | ||||||||
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| 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 | 207ZP0102X | 245122 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.