Healthcare Provider Details

I. General information

NPI: 1184178121
Provider Name (Legal Business Name): PHG MEDICAL OFFICE, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 MILITARY TPKE
PLATTSBURGH NY
12901-7375
US

IV. Provider business mailing address

1942 MILITARY TPKE
PLATTSBURGH NY
12901-7375
US

V. Phone/Fax

Practice location:
  • Phone: 518-310-3644
  • Fax: 518-310-3645
Mailing address:
  • Phone: 518-310-3644
  • Fax: 518-310-3645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number096889
License Number StateNY

VIII. Authorized Official

Name: MR. DONALD M WERNER
Title or Position: OWNER
Credential: MD
Phone: 518-310-3644