MEDICARE: COMMUNITY CARE PHYSICIANS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	192285	NY

General Provider Information

NPI Number	:	1093097586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE PHYSICIANS, PC

Provider Business Mailing Address
First Line	:	711 TROY SCHENECTADY RD STE 203
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2461
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	2524 US ROUTE 9W
Second Line	:
City	:	RAVENA
State	:	NY
Zip	:	12143-2804
Country	:	US
Telephone Number	:	518-756-7390
Fax Number	:	518-756-8030

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	DEBBY COONS
Credential	:
Telephone Number	:	518-213-0478

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	03/14/2019

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