Provider Demographics
NPI:1851437339
Name:NORTHERN LIGHTS SLEEP MEDICINE, PC
Entity Type:Organization
Organization Name:NORTHERN LIGHTS SLEEP MEDICINE, PC
Other - Org Name:CHAMPLAIN VALLEY PULMONARY ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:BUNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-562-7705
Mailing Address - Street 1:206 CORNELIA ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2779
Mailing Address - Country:US
Mailing Address - Phone:518-562-7705
Mailing Address - Fax:518-562-7706
Practice Address - Street 1:206 CORNELIA ST
Practice Address - Street 2:SUITE 307
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2779
Practice Address - Country:US
Practice Address - Phone:518-562-7705
Practice Address - Fax:518-562-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00608255Medicaid
NY51601AMedicare ID - Type Unspecified