Healthcare Provider Details

I. General information

NPI: 1518136001
Provider Name (Legal Business Name): ADIRONDACK MEDICAL PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3384 RT 22
PERU NY
12972
US

IV. Provider business mailing address

3384 RT 22
PERU NY
12972
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF331788
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006858-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number009293-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number162323-1
License Number StateNY

VIII. Authorized Official

Name: ANTHONY FRANCIS POLITI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 518-643-8008