Provider Demographics
NPI:1912957788
Name:ACKERMAN-RAPHAEL, REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ACKERMAN-RAPHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 GREEN STREET
Mailing Address - Street 2:STE 2
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-339-3736
Mailing Address - Fax:845-339-6731
Practice Address - Street 1:105 MARY'S AVENUE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-338-2500
Practice Address - Fax:845-334-3172
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2209052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H36509Medicare UPIN
NY718R11Medicare PIN