1518926401 NPI number — ST MARYS HEALTHCARE

Table of content: (NPI 1518926401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518926401 NPI number — ST MARYS HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MARYS 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:
Provider Other Organization Name Type Code:
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:
1518926401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
427 GUY PARK AVE
Provider Second Line Business Mailing Address:
ST MARYS HEALTHCARE -PRIMARY&SPECIALTY CARE
Provider Business Mailing Address City Name:
AMSTERDAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12010-1054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-841-7407
Provider Business Mailing Address Fax Number:
518-841-7121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
427 GUY PARK AVE
Provider Second Line Business Practice Location Address:
ST MARYS HEALTHCARE PRIMARY CARE DEPT
Provider Business Practice Location Address City Name:
AMSTERDAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12010-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-841-7407
Provider Business Practice Location Address Fax Number:
518-841-7121
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIRECTOR PRIMARY & SPECIALTY CARE
Authorized Official Telephone Number:
518-841-7407

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02176332 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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