Healthcare Provider Details

I. General information

NPI: 1093771677
Provider Name (Legal Business Name): PRIME COLUMBIA GREENE MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 COLUMBIA ST
HUDSON NY
12534-2624
US

IV. Provider business mailing address

949 COLUMBIA ST
HUDSON NY
12534-2624
US

V. Phone/Fax

Practice location:
  • Phone: 518-828-7188
  • Fax: 518-828-5049
Mailing address:
  • Phone: 518-828-7188
  • Fax: 518-828-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number209006
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number109985
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number123180
License Number StateNY

VIII. Authorized Official

Name: CLARENCE B HENRY
Title or Position: PRESIDENT
Credential: MD
Phone: 518-828-7188