Provider Demographics
NPI:1942292925
Name:THETA PATTISON MD
Entity Type:Organization
Organization Name:THETA PATTISON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THETA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-690-0177
Mailing Address - Street 1:PO BOX 9312
Mailing Address - Street 2:THETA PATTISON MD
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-0312
Mailing Address - Country:US
Mailing Address - Phone:518-690-0177
Mailing Address - Fax:
Practice Address - Street 1:2508 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-9485
Practice Address - Country:US
Practice Address - Phone:518-690-0177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02042400OtherGROUP MEDICAID
NY02042400OtherGROUP MEDICAID