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General NPI Number Information
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NPI Number | 1336654052
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Entity Type | Organization
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Legal Business Name | HOOSICK STREET PEDIATRICS, PLLC
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Dates
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Enumeration Date | 12/04/2017
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Last Update Date | 12/04/2017
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Provider Practice Location Address
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Address Line | 333 HOOSICK ST
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City | TROY
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State | NY
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Zip | 12180-2042
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Country | US
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Telephone | 518-273-3732
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Fax | 518-273-3732
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Provider Business Mailing Address
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Address Line | 333 HOOSICK ST
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City | TROY
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State | NY
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Zip | 12180-2042
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Country | US
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Telephone | 518-273-3732
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. SCOTT SHAVER
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Credential |
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Telephone | 518-273-3732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 203943-1
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License Number State | NY
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