Provider Demographics
NPI:1083915268
Name:LAKE CHAMPLAIN PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:LAKE CHAMPLAIN PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WOUTER
Authorized Official - Middle Name:
Authorized Official - Last Name:RIETSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-562-7330
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-562-7541
Mailing Address - Fax:518-562-7542
Practice Address - Street 1:210 CORNELIA ST
Practice Address - Street 2:SUITE 303
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2318
Practice Address - Country:US
Practice Address - Phone:518-562-7541
Practice Address - Fax:518-562-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty