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General NPI Number Information
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NPI Number | 1275635591
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Entity Type | Organization
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Legal Business Name | GLENS FALLS OBSTETRICS & GYNECOLOGY PC
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Dates
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Enumeration Date | 09/05/2006
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Last Update Date | 06/02/2015
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Provider Practice Location Address
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Address Line | 28 S WESTERN AVE
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City | QUEENSBURY
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State | NY
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Zip | 12804-3323
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Country | US
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Telephone | 518-798-6165
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Fax | 518-798-0658
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Provider Business Mailing Address
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Address Line | 28 SO WESTERN AVENUE
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City | QUEENSBURY
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State | NY
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Zip | 12804
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Country | US
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Telephone | 518-798-6165
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Fax | 518-798-0658
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DOUGLAS PROVOST
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Credential | MD
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Telephone | 518-798-6165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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