Provider Demographics
NPI:1831712181
Name:NORTHERN MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:NORTHERN MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-592-4915
Mailing Address - Street 1:111 CLOCK TOWER CMNS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-279-5187
Mailing Address - Fax:845-279-5168
Practice Address - Street 1:400 WESTAGE BUSINESS CTR DR STE 211
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2267
Practice Address - Country:US
Practice Address - Phone:845-226-4590
Practice Address - Fax:845-896-6982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04755717Medicaid