1811004096 NPI number — KPH HEALTHCARE SERVICES, INC.

Table of content: (NPI 1811004096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811004096 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:
1811004096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/04/2024
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:
7395 UTICA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOWVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13367-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-302-5466
Provider Business Practice Location Address Fax Number:
315-302-5467
Provider Enumeration Date:
08/24/2006

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:  013967 , 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: 3335420 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00562056 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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