=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821081175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL A IPSEN MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 NEW SCOTLAND RD SUITE 204
-----------------------------------------------------
City | SLINGERLANDS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12159-9222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-439-5624
-----------------------------------------------------
Fax | 518-765-4036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 NEW SCOTLAND RD SUITE 204
-----------------------------------------------------
City | SLINGERLANDS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12159-9222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-439-5624
-----------------------------------------------------
Fax | 518-765-4036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CAROL A IPSEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 518-439-5624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 149998
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------