Basic Information
| Provider Information | |||||||||
| NPI: | 1104983329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NYS OFFICE OF MENTAL HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAGAMORE CHILDRENS PSYCHIATRIC CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122290001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184738234 | ||||||||
| FaxNumber: | 5184735167 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 HALF HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | DIX HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117465861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316737700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | GIARRUSSO | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5184733598 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00769282 | 05 | NY | MEDICAID |