Healthcare Provider Details

I. General information

NPI: 1346463940
Provider Name (Legal Business Name): NORTH COUNTRY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 GLEN ST
GLENS FALLS NY
12801-2906
US

IV. Provider business mailing address

461 GLEN ST
GLENS FALLS NY
12801-2906
US

V. Phone/Fax

Practice location:
  • Phone: 518-745-5889
  • Fax: 518-745-0010
Mailing address:
  • Phone: 518-745-5889
  • Fax: 518-745-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIANE MARIE MACDONNELL
Title or Position: PROPRIETOR
Credential: M.D.
Phone: 518-745-5889