Provider Demographics
NPI:1750492740
Name:MS CENTER OF NORTHEASTERN NEW YORK, PC
Entity Type:Organization
Organization Name:MS CENTER OF NORTHEASTERN NEW YORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-785-1000
Mailing Address - Street 1:6 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:HOOSICK FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12090-1604
Mailing Address - Country:US
Mailing Address - Phone:518-205-5153
Mailing Address - Fax:518-205-5238
Practice Address - Street 1:1205 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1074
Practice Address - Country:US
Practice Address - Phone:518-785-1000
Practice Address - Fax:518-785-5000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0991Medicare PIN