Provider Demographics
NPI:1114340510
Name:UPSTATE PHYSICIAN SERVICES, PC
Entity Type:Organization
Organization Name:UPSTATE PHYSICIAN SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSTAFAIN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MEGHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-687-1960
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-0162
Mailing Address - Country:US
Mailing Address - Phone:518-687-1960
Mailing Address - Fax:518-687-1970
Practice Address - Street 1:2001 5TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3482
Practice Address - Country:US
Practice Address - Phone:518-687-1960
Practice Address - Fax:518-687-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 1041C0700X, 133V00000X, 207R00000X, 207RA0401X, 2084P0800X, 208M00000X
NY171212063261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03925651Medicaid
NY04646599Medicaid