Basic Information
| Provider Information | |||||||||
| NPI: | 1578577417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOHAWK VALLEY ORTHOPEDICS, P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5010 STATE HIGHWAY 30 STE 205 | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188422663 | ||||||||
| FaxNumber: | 5188424861 | ||||||||
| Practice Location | |||||||||
| Address1: | 5010 STATE HIGHWAY 30 STE 205 | ||||||||
| Address2: | |||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120107532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188422663 | ||||||||
| FaxNumber: | 5188424861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CECIL, M.D. | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | N.A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5188422663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1578577417 | 01 | NY | MEDICARE RAILROAD | OTHER | 02049750 | 05 | NY | MEDICAID |