Provider Demographics
NPI:1487898425
Name:FAMILY MEDICINE OF MECHANICVILLE PLLC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF MECHANICVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:BERMUDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-664-4185
Mailing Address - Street 1:242 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-3522
Mailing Address - Country:US
Mailing Address - Phone:518-664-4185
Mailing Address - Fax:518-539-2003
Practice Address - Street 1:242 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-3522
Practice Address - Country:US
Practice Address - Phone:518-664-4185
Practice Address - Fax:518-539-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236934261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI41835Medicare UPIN