1245347962 NPI number — KPH HEALTHCARE SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245347962 NPI number — KPH HEALTHCARE SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KPH HEALTHCARE SERVICES, 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:
6
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:
1245347962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOUVERNEUR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13642-1401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-287-3600
Provider Business Mailing Address Fax Number:
315-287-4291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13021-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-255-0014
Provider Business Practice Location Address Fax Number:
315-255-1947
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARLOW
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
315-287-3600

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  025573 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3329225 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02353331 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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