Healthcare Provider Details

I. General information

NPI: 1366486367
Provider Name (Legal Business Name): CARL R WIRTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CARSTEAD DR
SLINGERLANDS NY
12159-9793
US

IV. Provider business mailing address

90 CARSTEAD DR
SLINGERLANDS NY
12159-9793
US

V. Phone/Fax

Practice location:
  • Phone: 518-439-9417
  • Fax:
Mailing address:
  • Phone: 518-439-9417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number099341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: