Provider Demographics
NPI:1225179393
Name:FORD, MICHELINE R (MD)
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:R
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELINE
Other - Middle Name:R
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:124 ROSA ROAD
Mailing Address - Street 2:
Mailing Address - City:SCHENCTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2144
Mailing Address - Country:US
Mailing Address - Phone:518-386-3691
Mailing Address - Fax:518-386-3553
Practice Address - Street 1:124 ROSA ROAD
Practice Address - Street 2:SUITE 382
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2144
Practice Address - Country:US
Practice Address - Phone:518-386-3691
Practice Address - Fax:518-386-3553
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198459207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02132341Medicaid
J400016932OtherMEDICARE PTAN
J400016932OtherMEDICARE PTAN