Provider Demographics
NPI:1114970118
Name:LAKE CHAMPLAIN CARDIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:LAKE CHAMPLAIN CARDIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:WOLKOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-563-2404
Mailing Address - Street 1:52 TOM MILLER RD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1252
Mailing Address - Country:US
Mailing Address - Phone:518-563-2404
Mailing Address - Fax:518-563-4033
Practice Address - Street 1:52 TOM MILLER RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1252
Practice Address - Country:US
Practice Address - Phone:518-563-2404
Practice Address - Fax:518-563-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54426AMedicare UPIN