Basic Information
| Provider Information | |||||||||
| NPI: | 1710269907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CARE PHYSICIANS, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY CARE PEDIATRICS - MALTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HEMPHILL PL | ||||||||
| Address2: | BUILDING 3, SUITE 123 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120204422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185840355 | ||||||||
| FaxNumber: | 5185837665 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2011 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | STAMAS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5187823742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 206716 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.