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	207R00000X	Internal Medicine Physician	134658	NY

General Provider Information

NPI Number	:	1285905786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE PHYSICIANS, PC

Provider Business Mailing Address
First Line	:	711 TROY SCHENECTADY RD
Second Line	:	SUITE 203
City	:	LATHAM
State	:	NY
Zip	:	12110-2442
Country	:	US
Telephone Number	:	518-782-3700
Fax Number	:	518-782-3799

Provider Business Practice Location Address
First Line	:	199 DELAWARE AVE
Second Line	:
City	:	DELMAR
State	:	NY
Zip	:	12054-1229
Country	:	US
Telephone Number	:	518-439-1131
Fax Number	:	518-439-6306

Authorized Official
Title or Position	:	SENIOR CREDENTIALING COORDINATOR
Name	:	DIANE M STAMAS
Credential	:
Telephone Number	:	518-782-3742

Provider Enumeration Date	:	01/16/2012
Last Update Date	:	01/16/2012

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