Provider Demographics
NPI:1033141932
Name:GREENVILLE MEDICAL ASSOCIATE, PC
Entity Type:Organization
Organization Name:GREENVILLE MEDICAL ASSOCIATE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUBICKI
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:518-966-4433
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12083-0098
Mailing Address - Country:US
Mailing Address - Phone:518-966-4433
Mailing Address - Fax:518-966-4728
Practice Address - Street 1:77 COUNTY ROUTE 26A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12083-3921
Practice Address - Country:US
Practice Address - Phone:518-966-4433
Practice Address - Fax:518-966-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2339383OtherUNITEDHEALTHCARE
NYK262OtherCDPHP GROUP #
NY239713OtherWELLCARE
NY5996886OtherGHI PPO
NY711974OtherMVP
NY02506687Medicaid
NY7828474OtherAETNA
NY000000077419OtherGHI HMO
NYBSNENYOther000404955001
NY5205B1Medicare ID - Type UnspecifiedMEDICARE
NY2339383OtherUNITEDHEALTHCARE