Basic Information
| Provider Information | |||||||||
| NPI: | 1659332575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYER-MARTIN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KYLE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
| FaxNumber: | 5186494094 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 EMPIRE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENSSELAER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121445730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182864899 | ||||||||
| FaxNumber: | 5182864859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 212822 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02085243 | 05 | NY | MEDICAID |