Provider Demographics
NPI:1093771677
Name:PRIME COLUMBIA GREENE MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:PRIME COLUMBIA GREENE MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-828-7188
Mailing Address - Street 1:949 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2624
Mailing Address - Country:US
Mailing Address - Phone:518-828-7188
Mailing Address - Fax:518-828-5049
Practice Address - Street 1:949 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2624
Practice Address - Country:US
Practice Address - Phone:518-828-7188
Practice Address - Fax:518-828-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209006207R00000X
NY109985207RG0100X
NY123180208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00195813Medicaid
NY02311659Medicaid
NYA65044Medicare UPIN
NYWEB342Medicare PIN
NYWEB343Medicare PIN
NY00195813Medicaid