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	208000000X	Pediatrics Physician	258377	NY

General Provider Information

NPI Number	:	1679845366
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	:	1735 ROUTE 9
Second Line	:
City	:	CLIFTON PARK
State	:	NY
Zip	:	12065-2421
Country	:	US
Telephone Number	:	518-640-6732
Fax Number	:	518-383-6737

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

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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