=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982888988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL REGION RETINA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 12/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 WASHINGTON AVE SUITE 101
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12206-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-437-1111
-----------------------------------------------------
Fax | 518-435-1114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 WASHINGTON AVE SUITE 101
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12206-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-437-1111
-----------------------------------------------------
Fax | 518-435-1114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY H ATERN
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 518-437-1111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 184437
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------