Basic Information
| Provider Information | |||||||||
| NPI: | 1831553387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SARATOGA HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SARATOGA FAMILY PHYSICIANS AT MALTA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120205061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182892718 | ||||||||
| FaxNumber: | 5185838796 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120205061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182892718 | ||||||||
| FaxNumber: | 5185838796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5188865800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SARATOGA HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.