Healthcare Provider Details

I. General information

NPI: 1144396656
Provider Name (Legal Business Name): ECKARDT JOHANNING M.D., M.SC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EXECUTIVE PARK DR
ALBANY NY
12203-3718
US

IV. Provider business mailing address

4 EXECUTIVE PARK DR
ALBANY NY
12203-3718
US

V. Phone/Fax

Practice location:
  • Phone: 518-459-3336
  • Fax: 518-459-4646
Mailing address:
  • Phone: 518-459-3336
  • Fax: 518-459-4646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number175278-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number175278-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: