Basic Information
| Provider Information | |||||||||
| NPI: | 1811290786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME COLUMBIA GREENE MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 949 COLUMBIA STREET | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188287188 | ||||||||
| FaxNumber: | 5188282387 | ||||||||
| Practice Location | |||||||||
| Address1: | 949 COLUMBIA STREET | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188287188 | ||||||||
| FaxNumber: | 5188282387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | CLARANCE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5189431442 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F305407-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.