Provider Demographics
NPI:1154490944
Name:CHAMPLAIN VALLEY PSYCHIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:CHAMPLAIN VALLEY PSYCHIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-561-0063
Mailing Address - Street 1:11 HAMMOND LANE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2003
Mailing Address - Country:US
Mailing Address - Phone:518-561-0063
Mailing Address - Fax:518-561-0947
Practice Address - Street 1:11 HAMMOND LANE
Practice Address - Street 2:SUITE A
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2003
Practice Address - Country:US
Practice Address - Phone:518-561-0063
Practice Address - Fax:518-561-0947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGRP490098001OtherBLUESHIELD OF NORTHEASTERN NY
NYGRP490098001OtherBLUESHIELD OF NORTHEASTERN NY