Provider Demographics
NPI:1871605394
Name:JOHN A BRENDESE MD PC
Entity type:Organization
Organization Name:JOHN A BRENDESE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BRENDESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-274-2030
Mailing Address - Street 1:297 HOOSICK ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-272-3493
Mailing Address - Fax:
Practice Address - Street 1:2402 22ND STREET
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-274-2030
Practice Address - Fax:518-274-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86830207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000029374OtherGH1
NY000406531001OtherBS OF NORTHEASTERN NY
NY000406531001OtherBS OF NORTHEASTERN NY
NY000000029374OtherGH1