=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386753119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRACTICE OF HUDSON FALLS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 03/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340A MAIN ST
-----------------------------------------------------
City | HUDSON FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12839-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-747-4117
-----------------------------------------------------
Fax | 518-747-9837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340A MAIN STREET
-----------------------------------------------------
City | HUDSON FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-747-4117
-----------------------------------------------------
Fax | 518-747-9837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. BONNIE L BALLWEBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-747-4117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------