Provider Demographics
NPI:1891977559
Name:UPSTATE MEDICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:UPSTATE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISHNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-843-0500
Mailing Address - Street 1:446B GUY PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-843-0500
Mailing Address - Fax:518-843-0600
Practice Address - Street 1:446B GUY PARK AVE.
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1005
Practice Address - Country:US
Practice Address - Phone:518-843-0500
Practice Address - Fax:518-843-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181783174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1041Medicare PIN