Basic Information
| Provider Information | |||||||||
| NPI: | 1598829582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGMAN | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MOSES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 PATTERSON ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136693840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153939113 | ||||||||
| FaxNumber: | 3153939127 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 LEROY STREET | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 166862-1 | NY | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 166862-1 | 01 | NY | LICENSE | OTHER |