1447227491 NPI number — HEALTHALLIANCE MARYS AVENUE CAMPUS

Table of content: (NPI 1447227491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447227491 NPI number — HEALTHALLIANCE MARYS AVENUE CAMPUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHALLIANCE MARYS AVENUE CAMPUS
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:
1447227491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 MARY'S AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-943-6007
Provider Business Mailing Address Fax Number:
845-943-6038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MARY'S AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-943-6007
Provider Business Practice Location Address Fax Number:
845-943-6038
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHUPP
Authorized Official First Name:
MAUREEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PATIENT ACCOUNTS
Authorized Official Telephone Number:
845-943-6007

Provider Taxonomy Codes

  • Taxonomy code: 273Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00274020 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10005742 . This is a "CDPHP PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3185 . This is a "GHI PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000302 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: UV5282 . This is a "MVP PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 103185 . This is a "WELLCARE PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6450795 . This is a "AETNA PROVIDER ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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