Healthcare Provider Details

I. General information

NPI: 1700979507
Provider Name (Legal Business Name): POUGHKEEPSIE MEDICAL GROUP LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 HOOKER AVE.
POUGHKEEPSIE NY
12603
US

IV. Provider business mailing address

375 HOOKER AVE
POUGHKEEPSIE NY
12603
US

V. Phone/Fax

Practice location:
  • Phone: 845-454-5000
  • Fax: 845-454-9880
Mailing address:
  • Phone: 845-454-5000
  • Fax: 845-454-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUMITA MAZUMDAR
Title or Position: BILLING SUPERVISIOR
Credential: MD
Phone: 845-454-5000