Basic Information
| Provider Information | |||||||||
| NPI: | 1801978184 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOHAWK VALLEY PLASTIC & RECONSTRUCTIVE SURGERY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 MIDDLE SETTLEMENT RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134135332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157354996 | ||||||||
| FaxNumber: | 3157357066 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 MIDDLE SETTLEMENT RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134135332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157354996 | ||||||||
| FaxNumber: | 3157357066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | ORLANDO | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3152660407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 199751 | NY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0105X | 199751 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 02636208 | 05 | NY | MEDICAID |