Basic Information
Provider Information | |||||||||
NPI: | 1811921786 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALBANY MEDICAL COLLEGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALBANY MEDICAL COLLEGE DEPT OF NEUROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1275 BROADWAY # 106 | ||||||||
Address2: |   | ||||||||
City: | MENANDS | ||||||||
State: | NY | ||||||||
PostalCode: | 122042638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182629705 | ||||||||
FaxNumber: | 5182629638 | ||||||||
Practice Location | |||||||||
Address1: | 47 NEW SCOTLAND AVE | ||||||||
Address2: | MAIL CODE 61 | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122083412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182626517 | ||||||||
FaxNumber: | 5182620871 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 04/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VERDILE | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | DEAN | ||||||||
AuthorizedOfficialTelephone: | 5182626008 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 04/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 103T00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 2084N0402X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084P0005X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurodevelopmental Disabilities | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 2084N0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 01520676 | 05 | NY |   | MEDICAID | 01001472 | 05 | NY |   | MEDICAID | 1006966 | 05 | VT |   | MEDICAID | 9766804 | 05 | MA |   | MEDICAID |