Provider Demographics
NPI:1194838748
Name:CAPITAL REGION OTOLARYNGOLOGY HEAD & NECK GROUP. LLP
Entity Type:Organization
Organization Name:CAPITAL REGION OTOLARYNGOLOGY HEAD & NECK GROUP. LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUFF-CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-482-3131
Mailing Address - Street 1:6 EXECUTIVE PARK DR # C
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3791
Mailing Address - Country:US
Mailing Address - Phone:518-482-9111
Mailing Address - Fax:518-482-6142
Practice Address - Street 1:6 EXECUTIVE PARK DR # C
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3791
Practice Address - Country:US
Practice Address - Phone:518-482-9111
Practice Address - Fax:518-482-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33680AMedicare ID - Type Unspecified