Healthcare Provider Details

I. General information

NPI: 1104829357
Provider Name (Legal Business Name): PHILIP T DREW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 PAXWOOD ROAD
DELMAR NY
12054
US

IV. Provider business mailing address

79 PAXWOOD ROAD
DELMAR NY
12054
US

V. Phone/Fax

Practice location:
  • Phone: 518-439-8555
  • Fax: 518-439-8145
Mailing address:
  • Phone: 518-439-0509
  • Fax: 518-439-8145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number150805
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: