Basic Information
| Provider Information | |||||||||
| NPI: | 1952911414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN NEW YORK PHYSICIAN SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2005 | ||||||||
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| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154490513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 IRONGATE CTR | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187455423 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2020 | ||||||||
| LastUpdateDate: | 08/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | HERLIHY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER-AUTH SIGNATORY | ||||||||
| AuthorizedOfficialTelephone: | 5187455423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.