Basic Information
| Provider Information | |||||||||
| NPI: | 1710960067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEDESCO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3 IRONGATE CENTER | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
| FaxNumber: | 5187935886 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 IRONGATE CENTER | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
| FaxNumber: | 5187935886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 095746 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10002028 | 01 | NY | CDPHP | OTHER | 000000051341 | 01 | NY | GHI-HMO | OTHER | 000401447001 | 01 | NY | BLUE SHIELD NENY | OTHER | 002120070050 | 01 | NY | FIDELIS | OTHER | 00360976 | 05 | NY | MEDICAID | 496541 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 5456200 | 01 | NY | AETNA | OTHER | 10507494 | 01 | NY | CAQH | OTHER | 0002090 | 01 | NY | UNIVERA | OTHER | 08178 | 01 | NY | MVP | OTHER | CD1981 | 01 | NY | RAILROAD MEDICARE GROUP # | OTHER |