Provider Demographics
NPI:1700838158
Name:EBRAHIMI-FARD, BEHROOZ (MD)
Entity Type:Individual
Prefix:DR
First Name:BEHROOZ
Middle Name:
Last Name:EBRAHIMI-FARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BROAD STREET PLZ
Mailing Address - Street 2:ADIRONDACK MEDICAL SERVICES
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4369
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:GLENS FALLS HOSPITAL - BEHAVIORAL HEALTH SERV
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-3210
Practice Address - Fax:518-926-3215
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY220273-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02300461Medicaid
NY02300461Medicaid
NYJ400139585Medicare PIN