Provider Demographics
NPI:1144302217
Name:NORTH COUNTRY SPORTS MEDICINE PLLC
Entity type:Organization
Organization Name:NORTH COUNTRY SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:M
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-793-9156
Mailing Address - Street 1:25 WILLOWBROOK ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804
Mailing Address - Country:US
Mailing Address - Phone:518-793-9156
Mailing Address - Fax:518-793-6591
Practice Address - Street 1:25 WILLOWBROOK ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804
Practice Address - Country:US
Practice Address - Phone:518-793-9156
Practice Address - Fax:518-793-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194627Medicaid
AA0798Medicare ID - Type Unspecified
NYAA0798Medicare PIN
NY02194627Medicaid