Healthcare Provider Details

I. General information

NPI: 1477626703
Provider Name (Legal Business Name): STANKO RODIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COULTER ROAD BEHAVIORAL HEALTH
CLIFTON SPRINGS NY
14432
US

IV. Provider business mailing address

2 COULTER ROAD CLIFTON SPRINGS HOSPITAL & CLINIC ATTN MED STAFF OFF
CLIFTON SPRINGS NY
14432
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-1465
  • Fax: 315-462-0145
Mailing address:
  • Phone: 315-462-1464
  • Fax: 315-462-2487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number125644
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: