Healthcare Provider Details

I. General information

NPI: 1740728013
Provider Name (Legal Business Name): UPSTATE PHYSICIAN SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 5TH AVENUE SUITE 110
TROY NY
12180
US

IV. Provider business mailing address

2001 5TH AVENUE
TROY NY
12180
US

V. Phone/Fax

Practice location:
  • Phone: 518-687-1960
  • Fax: 518-687-1970
Mailing address:
  • Phone: 518-687-1960
  • Fax: 518-687-1970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number171212063
License Number StateNY

VIII. Authorized Official

Name: MUSTAFAIN MEGHANI
Title or Position: OWNER
Credential: MD
Phone: 518-687-1960