1972754380 NPI number — CAPITAL DISTRICT ORTHOTIC GROUP

Table of content: (NPI 1972754380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972754380 NPI number — CAPITAL DISTRICT ORTHOTIC GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL DISTRICT ORTHOTIC GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972754380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2341 NOTT ST E
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
NISKAYUNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12309-4332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-370-3338
Provider Business Mailing Address Fax Number:
518-344-1229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12205-5052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-608-6852
Provider Business Practice Location Address Fax Number:
518-344-1229
Provider Enumeration Date:
10/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RATTNER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
518-370-3338

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  180400-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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