Healthcare Provider Details

I. General information

NPI: 1144438128
Provider Name (Legal Business Name): JACK P PARILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 GILBERT ST CAMBRIDGE FAMILY HEALTH CENTER
CAMBRIDGE NY
12816-2618
US

IV. Provider business mailing address

PO BOX 304
GLENS FALLS NY
12801-0304
US

V. Phone/Fax

Practice location:
  • Phone: 518-677-3961
  • Fax: 518-677-3180
Mailing address:
  • Phone: 518-677-3961
  • Fax: 518-677-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number145074-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number145074
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: