Provider Demographics
NPI:1164674347
Name:NORTH COUNTRY PODIATRY
Entity Type:Organization
Organization Name:NORTH COUNTRY PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GEOFFREY
Authorized Official - Last Name:GRESSER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-331-3338
Mailing Address - Street 1:626 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-3309
Mailing Address - Country:US
Mailing Address - Phone:631-331-3338
Mailing Address - Fax:631-331-0014
Practice Address - Street 1:626 CANAL RD
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-3309
Practice Address - Country:US
Practice Address - Phone:631-331-3338
Practice Address - Fax:631-331-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003743213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00886888Medicaid