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General NPI Number Information
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NPI Number | 1588928022
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Entity Type | Organization
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Legal Business Name | NORTH COUNTRY SPORTS MEDICINE PPLC
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Dates
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Enumeration Date | 06/29/2012
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 1134 STATE ROUTE 29
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City | GREENWICH
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State | NY
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Zip | 12834-6107
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Country | US
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Telephone | 518-793-9156
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Fax | 518-793-6591
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Provider Business Mailing Address
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Address Line | 25 WILLOWBROOK RD SUITE 2
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City | QUEENSBURY
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State | NY
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Zip | 12804-5882
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Country | US
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Telephone | 518-793-9156
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Fax | 518-793-6591
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | LORI BALDWIN
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Credential |
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Telephone | 518-793-9156
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 181379
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License Number State | NY
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