Provider Demographics
NPI:1275635591
Name:GLENS FALLS OBSTETRICS & GYNECOLOGY PC
Entity Type:Organization
Organization Name:GLENS FALLS OBSTETRICS & GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-798-6165
Mailing Address - Street 1:28 SO WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804
Mailing Address - Country:US
Mailing Address - Phone:518-798-6165
Mailing Address - Fax:518-798-0658
Practice Address - Street 1:28 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3323
Practice Address - Country:US
Practice Address - Phone:518-798-6165
Practice Address - Fax:518-798-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty