Provider Demographics
NPI:1457395279
Name:ADIRONDACK REHABILITATION MEDICINE PLLC
Entity Type:Organization
Organization Name:ADIRONDACK REHABILITATION MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:R
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-798-0767
Mailing Address - Street 1:17 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-4007
Mailing Address - Country:US
Mailing Address - Phone:518-798-0767
Mailing Address - Fax:518-798-0815
Practice Address - Street 1:17 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-4007
Practice Address - Country:US
Practice Address - Phone:518-798-0767
Practice Address - Fax:518-798-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01902547Medicaid
NY01902547Medicaid