Active NPI
Glenn Champagne, M.D.
- General Practice Physician
- Malone, NY
National Provider Identifier
1487869087
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Physician
- License
- 127279-1
- Practice address
- Bare Hill Road
Franklin Correctional Facility
Malone, NY 12953 - Phone
- (518) 483-6040
- NPI assigned
- May 14, 2007
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Physician | 208D00000X | 127279-1 | NY | Primary |
Addresses
Primary practice location
Bare Hill Road
Franklin Correctional Facility
Malone, NY 12953
Mailing address
130 Moody Rd
Malone, NY 12953-3819
Phone (518) 483-1120
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00632522 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 127279-1 | NY | MD | General Practice Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179100800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1487869087",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "130 MOODY RD",
"city": "MALONE",
"state": "NY",
"postal_code": "129533819",
"telephone_number": "518-483-1120"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "BARE HILL ROAD",
"address_2": "FRANKLIN CORRECTIONAL FACILITY",
"city": "MALONE",
"state": "NY",
"postal_code": "12953",
"telephone_number": "518-483-6040"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CHAMPAGNE",
"first_name": "GLENN",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-05-14",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "208D00000X",
"taxonomy_group": "",
"desc": "General Practice",
"state": "NY",
"license": "127279-1",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00632522",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Malone, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.