Provider Demographics
NPI:1427137256
Name:MELBOURNE, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MELBOURNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2513
Mailing Address - Country:US
Mailing Address - Phone:518-370-5426
Mailing Address - Fax:
Practice Address - Street 1:600 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2107
Practice Address - Country:US
Practice Address - Phone:518-372-7031
Practice Address - Fax:518-372-7064
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2060981101YA0400X
NY206098208D00000X
NY206098-1207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NY52320HMedicare PIN
NY01420800Medicaid