Healthcare Provider Details

I. General information

NPI: 1447604202
Provider Name (Legal Business Name): CAROLYN HEINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN ELLSWORTH

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 MYRTLE AVE STE 4A
ALBANY NY
12208-3797
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD STE 203
LATHAM NY
12110-2461
US

V. Phone/Fax

Practice location:
  • Phone: 518-207-2273
  • Fax: 518-207-2293
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number299061
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number299061
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: