Provider Demographics
NPI:1528208881
Name:CHAMPLAIN VALLEY VASCULAR SURGERY
Entity Type:Organization
Organization Name:CHAMPLAIN VALLEY VASCULAR SURGERY
Other - Org Name:THEODORE S PABST III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:SHUSTER
Authorized Official - Last Name:PABST
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:518-562-7557
Mailing Address - Street 1:24 HAMMOND LANE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-562-7557
Mailing Address - Fax:518-562-7559
Practice Address - Street 1:24 HAMMOND LANE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-562-7557
Practice Address - Fax:518-562-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-26
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203101-12086S0129X
NY187640-12086S0129X
2086S0129X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01972430Medicaid
NY04556089Medicaid
NY01276613Medicaid
NY01276613Medicaid