Provider Demographics
NPI:1609826163
Name:UPSTATE DERMATOLOGY, PC
Entity Type:Organization
Organization Name:UPSTATE DERMATOLOGY, PC
Other - Org Name:UPPER HUDSON VALLEY DERMATOLOGY, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-694-5317
Mailing Address - Street 1:1547 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9543
Mailing Address - Country:US
Mailing Address - Phone:518-479-4156
Mailing Address - Fax:
Practice Address - Street 1:1547 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9543
Practice Address - Country:US
Practice Address - Phone:518-479-4156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173589207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY070014246OtherRAILROAD MEDICARE (PTAN)
NYD27004Medicare UPIN
NY070014246OtherRAILROAD MEDICARE (PTAN)
AA0422Medicare PIN