1609820265 NPI number — THE JAMES A. EDDY MEMORIAL GERIATRIC CENTER, INC.

Table of content: (NPI 1609820265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609820265 NPI number — THE JAMES A. EDDY MEMORIAL GERIATRIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE JAMES A. EDDY MEMORIAL GERIATRIC CENTER, 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:
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:
1609820265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 MOHAWK ST STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COHOES
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12047-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-274-9890
Provider Business Mailing Address Fax Number:
518-274-5407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2256 BURDETT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12180-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-274-9890
Provider Business Practice Location Address Fax Number:
518-274-5407
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHEELER-MOORE
Authorized Official First Name:
JUANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CBO
Authorized Official Telephone Number:
518-268-4906

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  4102309N , 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: 000400135001 . This is a "BLUE SHIELD OF NE NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7740256 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00545208 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10030782 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00872899 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009612 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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