Provider Demographics
NPI:1184178121
Name:PHG MEDICAL OFFICE, LLP
Entity type:Organization
Organization Name:PHG MEDICAL OFFICE, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-310-3644
Mailing Address - Street 1:1942 MILITARY TPKE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-7375
Mailing Address - Country:US
Mailing Address - Phone:518-310-3644
Mailing Address - Fax:518-310-3645
Practice Address - Street 1:1942 MILITARY TPKE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-7375
Practice Address - Country:US
Practice Address - Phone:518-310-3644
Practice Address - Fax:518-310-3645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096889261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00577413OtherMEDICADE PROVIDER NUMBER
NY11124926OtherCAQH
NY00577410Medicaid