Healthcare Provider Details

I. General information

NPI: 1487898425
Provider Name (Legal Business Name): FAMILY MEDICINE OF MECHANICVILLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 S CENTRAL AVE
MECHANICVILLE NY
12118-3522
US

IV. Provider business mailing address

242 S CENTRAL AVE
MECHANICVILLE NY
12118-3522
US

V. Phone/Fax

Practice location:
  • Phone: 518-664-4185
  • Fax: 518-539-2003
Mailing address:
  • Phone: 518-664-4185
  • Fax: 518-539-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number236934
License Number StateNY

VIII. Authorized Official

Name: DR. INGRID BERMUDEZ
Title or Position: OWNER
Credential: MD
Phone: 518-664-4185