Basic Information
| Provider Information | |||||||||
| NPI: | 1861598963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNEIFEL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | W | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD PLLC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNEIFEL | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | W | ||||||||
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| OtherCredential: | MD PLLC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152615852 | ||||||||
| Practice Location | |||||||||
| Address1: | 6119 US HIGHWAY 11 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152615850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2230681 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02361833 | 05 | NY | MEDICAID |