Provider Demographics
NPI:1013144823
Name:EAST GREENBUSH NEUROLOGY OFFICE, PLLC
Entity Type:Organization
Organization Name:EAST GREENBUSH NEUROLOGY OFFICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HANI
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-694-3053
Mailing Address - Street 1:1528 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9584
Mailing Address - Country:US
Mailing Address - Phone:518-694-3053
Mailing Address - Fax:518-694-3056
Practice Address - Street 1:1528 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9584
Practice Address - Country:US
Practice Address - Phone:518-694-3053
Practice Address - Fax:518-694-3056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2140142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB5753OtherMEDICARE ID-TYPE UNSPECIFIED
NY01954374Medicaid
RB0781Medicare PIN
NYG75413Medicare UPIN