Healthcare Provider Details

I. General information

NPI: 1902981871
Provider Name (Legal Business Name): ROGER ISHAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BEEKMAN ST. CVPH CARDIOLOGY
PLATTSBURGH NY
12901
US

IV. Provider business mailing address

75 BEEKMAN ST. CVPH CARDIOLOGY
PLATTSBURGH NY
12901
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-2404
  • Fax:
Mailing address:
  • Phone: 518-563-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD429478
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number042.0013217
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number241066
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT189586
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: