Basic Information
| Provider Information | |||||||||
| NPI: | 1710917638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBANY MEDICAL COLLEGE | ||||||||
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| OtherOrganizationName: | ALBANY MEDICAL COLLEGE DEPT OF TRAUMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 618 CENTRAL AVE | ||||||||
| Address2: | MC 106 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122061916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182629702 | ||||||||
| FaxNumber: | 5182629707 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | 61GE | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182625623 | ||||||||
| FaxNumber: | 5182625067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VERDILE | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DEAN | ||||||||
| AuthorizedOfficialTelephone: | 5182623773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01520676 | 05 | NY | MEDICAID | 01227141 | 05 | NY | MEDICAID | 9766804 | 05 | MA | MEDICAID | 1006966 | 05 | VT | MEDICAID |