Provider Demographics
NPI:1750471132
Name:SIRICO, THERESA A (DO)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:SIRICO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2524 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143
Practice Address - Country:US
Practice Address - Phone:518-756-7390
Practice Address - Fax:518-756-8030
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000401055002OtherBSNENY
NY200137OtherSENIOR WHOLE HEALTH
NY52560OtherGHI/HMO
NY08953OtherMVP
NY070322000009OtherFIDELIS
NY3686D1OtherEMPIRE BC
NY10021142OtherCDPHP
NY01670075Medicaid
NY5068652OtherAETNA
NY000401055002OtherBSNENY
NY10021142OtherCDPHP