1225122054 NPI number — KOINONIA HEALTHCARE

Table of content: (NPI 1225122054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225122054 NPI number — KOINONIA HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOINONIA HEALTHCARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KOINONIA PRIMARY CARE AND PSYCHIATRIC SERVICES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225122054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
553 CLINTON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-689-0282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
553 CLINTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-689-0282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAEGLOW
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
518-689-0282

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  60/201542 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01753680 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: G9202 . This is a "CDPHP GROUP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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