MEDICARE: NEUROLOGICAL CLINICAL ASSOCIATE 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	2084N0400X	Neurology Physician	120621-1	NY

General Provider Information

NPI Number	:	1144267956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROLOGICAL CLINICAL ASSOCIATE PC

Provider Business Mailing Address
First Line	:	760 MADISON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-3428
Country	:	US
Telephone Number	:	518-449-2662
Fax Number	:	518-449-1342

Provider Business Practice Location Address
First Line	:	760 MADISON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12208-3428
Country	:	US
Telephone Number	:	518-449-2662
Fax Number	:	518-449-1342

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD F HOLUB
Credential	:	M.D.
Telephone Number	:	518-449-2662

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	08/22/2020

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