Provider Demographics
NPI:1598829582
Name:BRIDGMAN, PHILLIP MOSES (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MOSES
Last Name:BRIDGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3840
Mailing Address - Country:US
Mailing Address - Phone:315-393-9113
Mailing Address - Fax:315-393-9127
Practice Address - Street 1:50 LEROY STREET
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-265-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166862-1207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY166862-1OtherLICENSE
NY166862-1OtherLICENSE
E85888Medicare UPIN
NYE65305Medicare UPIN
NY51714CMedicare PIN
NY51714AMedicare PIN