Healthcare Provider Details

I. General information

NPI: 1093097586
Provider Name (Legal Business Name): COMMUNITY CARE PHYSICIANS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 US ROUTE 9W
RAVENA NY
12143-2804
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD STE 203
LATHAM NY
12110-2461
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-7390
  • Fax: 518-756-8030
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number192285
License Number StateNY

VIII. Authorized Official

Name: DEBBY COONS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 518-213-0478