Provider Demographics
NPI:1396856530
Name:EMILY T. ETZKORN, M.D., P.C.
Entity Type:Organization
Organization Name:EMILY T. ETZKORN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CORPORATION HOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:T
Authorized Official - Last Name:ETZKORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:518-842-0017
Mailing Address - Street 1:5010 STATE HIGHWAY 30
Mailing Address - Street 2:SUITE G-02
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7532
Mailing Address - Country:US
Mailing Address - Phone:518-842-0017
Mailing Address - Fax:518-842-7545
Practice Address - Street 1:5010 STATE HIGHWAY 30
Practice Address - Street 2:SUITE G-02
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7532
Practice Address - Country:US
Practice Address - Phone:518-842-0017
Practice Address - Fax:518-842-7545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02047565Medicaid
NY02047565Medicaid