=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932721032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRALMED URGENT CARE AND PRIMARY CARE LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2020
-----------------------------------------------------
Last Update Date | 05/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1662 CENTRAL AVE
-----------------------------------------------------
City | COLONIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12205-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-240-1456
-----------------------------------------------------
Fax | 607-800-4134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1662 CENTRAL AVE
-----------------------------------------------------
City | COLONIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12205-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-240-1456
-----------------------------------------------------
Fax | 607-800-4134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NOSA D AIGBE LEBARTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 518-951-0740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------