1730379504 NPI number — CONIFER PARK, INC.

Table of content: (NPI 1730379504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730379504 NPI number — CONIFER PARK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONIFER PARK, 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:
1730379504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10092
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:
12201-5092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-985-8408
Provider Business Mailing Address Fax Number:
518-399-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 LAKE HILL ROAD
Provider Second Line Business Practice Location Address:
HAWLEY COTTAGE, 1ST FLOOR
Provider Business Practice Location Address City Name:
BURNT HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12027-9772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-399-8182
Provider Business Practice Location Address Fax Number:
518-372-7064
Provider Enumeration Date:
07/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETTEYS
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR OP BILLING
Authorized Official Telephone Number:
518-952-8140

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  081110730 , 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: 01420800 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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