Healthcare Provider Details

I. General information

NPI: 1578925632
Provider Name (Legal Business Name): TRAVIS BEVINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 NEW SCOTLAND AVE DEPT. OF INTERNAL MEDICINE
ALBANY NY
12208-3412
US

IV. Provider business mailing address

6 WELLNESS WAY STE 201
LATHAM NY
12110-2156
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5377
  • Fax:
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number221151324
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number316406
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: