Provider Demographics
NPI:1629344320
Name:MYRTLE STREET OBSTETRICS AND GYNECOLOGY, PC
Entity Type:Organization
Organization Name:MYRTLE STREET OBSTETRICS AND GYNECOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-587-5304
Mailing Address - Street 1:59 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1093
Mailing Address - Country:US
Mailing Address - Phone:518-587-2400
Mailing Address - Fax:518-581-0141
Practice Address - Street 1:2105 ELLSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-587-2400
Practice Address - Fax:518-581-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189300-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01877009Medicaid
NY33533AMedicare PIN