1578578126 NPI number — ST LUKE'S RESIDENTIAL HEALTHCARE FACILITY INC

Table of content: MRS. ANGELA SUAREZ SERIG OTRL, CHT (NPI 1396961058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578578126 NPI number — ST LUKE'S RESIDENTIAL HEALTHCARE FACILITY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKE'S RESIDENTIAL HEALTHCARE FACILITY INC
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:
MVHS REHABILITATION AND NURSING CENTER
Provider Other Organization Name Type Code:
3
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:
1578578126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2209 GENESEE ST/ BUSINESS OFFICE
Provider Second Line Business Mailing Address:
ROOM #315
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13501-5809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-801-3282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 CHAMPLIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-624-8600
Provider Business Practice Location Address Fax Number:
315-624-8685
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CODY
Authorized Official Middle Name:
Authorized Official Title or Position:
REVENUE CYCLE DIRECTOR
Authorized Official Telephone Number:
315-801-4429

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  3227305N , 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: 01661816 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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