Healthcare Provider Details

I. General information

NPI: 1306869672
Provider Name (Legal Business Name): ADIRONDACK HEALTHCARE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3384 STATE ROUTE 22
PERU NY
12972-5305
US

IV. Provider business mailing address

3384 STATE ROUTE 22
PERU NY
12972-5305
US

V. Phone/Fax

Practice location:
  • Phone: 518-643-8008
  • Fax: 518-643-8090
Mailing address:
  • Phone: 518-643-8008
  • Fax: 518-643-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006858-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331788
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number162323-1
License Number StateNY

VIII. Authorized Official

Name: AMY J MCDONALD
Title or Position: OFFICE MANAGER
Credential:
Phone: 518-643-8008