Provider Demographics
NPI:1194703199
Name:IVAN HERNANDEZ MD PC
Entity type:Organization
Organization Name:IVAN HERNANDEZ MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:AURELIO
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACS CWS FCCWS
Authorized Official - Phone:518-382-9585
Mailing Address - Street 1:1367 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-4019
Mailing Address - Country:US
Mailing Address - Phone:518-382-9585
Mailing Address - Fax:518-382-9685
Practice Address - Street 1:1367 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-3019
Practice Address - Country:US
Practice Address - Phone:518-382-9585
Practice Address - Fax:518-382-9685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093218-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYSP0208OtherMVP
NY00569195Medicaid
NY093218-6WOtherWORKERS COMPENSATION
NYB78852Medicare UPIN
NY00569195Medicaid