Provider Demographics
NPI:1801853122
Name:UPSTATE MEDICAL GROUP PC
Entity Type:Organization
Organization Name:UPSTATE MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:TROITINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-237-9708
Mailing Address - Street 1:2231 BURDETT AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-237-9708
Mailing Address - Fax:
Practice Address - Street 1:2231 BURDETT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-237-9708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH8587OtherMEDICARE ID
8644OtherMEDICARE ID
8644OtherMEDICARE PIN
CH8587OtherMEDICARE PIN
CH8587OtherMEDICARE PIN
AA0890Medicare ID - Type Unspecified