1619906344 NPI number — SARATOGA EMERGENCY CORP INC

Table of content: RUSSELL MATTHEW WOLBERS CRNA (NPI 1255481875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619906344 NPI number — SARATOGA EMERGENCY CORP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SARATOGA EMERGENCY CORP 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:
1619906344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWINSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-635-1789
Provider Business Mailing Address Fax Number:
315-635-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12866-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-584-2109
Provider Business Practice Location Address Fax Number:
518-584-2109
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAYWARD
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
518-584-2109

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  10576 , 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: 590007879 . This is a "PALMETTO RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000400139001 . This is a "BCBS OF NENY" identifier . This identifiers is of the category "OTHER".
  • Identifier: A1253727 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10018435 . This is a "CDPHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 702000 . This is a "MVP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01335102 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3200157 . This is a "GHI" identifier . This identifiers is of the category "OTHER".




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