Provider Demographics
NPI:1336238716
Name:RICHMAN, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:RICHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:6 MOUNTAIN LEDGE
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-2539
Practice Address - Country:US
Practice Address - Phone:518-584-0355
Practice Address - Fax:518-583-7665
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120641208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00381255Medicaid
NY00381255Medicaid