Healthcare Provider Details

I. General information

NPI: 1528238359
Provider Name (Legal Business Name): THOMAS BUBNACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MERCYCARE LN
GUILDERLAND NY
12084-3504
US

IV. Provider business mailing address

199 S ALLEN ST 3-3
ALBANY NY
12208-2060
US

V. Phone/Fax

Practice location:
  • Phone: 518-452-6769
  • Fax: 518-452-6706
Mailing address:
  • Phone: 518-452-6769
  • Fax: 518-452-6706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number040909
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: