Basic Information
| Provider Information | |||||||||
| NPI: | 1750315636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALBANY MEDICAL COLLEGE | ||||||||
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| OtherOrganizationName: | ALBANY MEDICAL COLLEGE DEPARTMENT OF PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 BROADWAY # MC106 | ||||||||
| Address2: | |||||||||
| City: | MENANDS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122042638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182629705 | ||||||||
| FaxNumber: | 5182629638 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 NEW SCOTLAND AVE | ||||||||
| Address2: | MC 88 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182625333 | ||||||||
| FaxNumber: | 5182624933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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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. | ||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0203X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0205X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology | 2080P0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0207X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0208X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 2080P0210X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0214X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0216X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01226993 | 05 | NY | MEDICAID | 01520676 | 05 | NY | MEDICAID | 1006966 | 05 | VT | MEDICAID | 9766804 | 05 | MA | MEDICAID |