Healthcare Provider Details

I. General information

NPI: 1083915268
Provider Name (Legal Business Name): LAKE CHAMPLAIN PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CORNELIA ST SUITE 303
PLATTSBURGH NY
12901-2318
US

IV. Provider business mailing address

PO BOX 2868
PLATTSBURGH NY
12901-0259
US

V. Phone/Fax

Practice location:
  • Phone: 518-562-7541
  • Fax: 518-562-7542
Mailing address:
  • Phone: 518-562-7541
  • Fax: 518-562-7542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WOUTER RIETSEMA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 518-562-7330