Healthcare Provider Details

I. General information

NPI: 1912545344
Provider Name (Legal Business Name): OLDENDORF MEDICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 EVERETT RD EXT
ALBANY NY
12205-3357
US

IV. Provider business mailing address

407 ALBANY SHAKER RD
ALBANY NY
12211-1900
US

V. Phone/Fax

Practice location:
  • Phone: 518-435-1300
  • Fax: 518-435-1397
Mailing address:
  • Phone: 518-435-1300
  • Fax: 518-435-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK OLDENDORF
Title or Position: OWNER
Credential:
Phone: 518-435-1300