Basic Information
Provider Information | |||||||||
NPI: | 1144565797 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GUTHRIE AHC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BH SATELLITE CLINIC-CARTHAGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11050 MOUNT BELVEDERE BLVD | ||||||||
Address2: | C/O UBO | ||||||||
City: | FORT DRUM | ||||||||
State: | NY | ||||||||
PostalCode: | 136025438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157724033 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 40 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | CARTHAGE | ||||||||
State: | NY | ||||||||
PostalCode: | 136191377 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157722778 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2012 | ||||||||
LastUpdateDate: | 03/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DRAPER | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ACTING UBO MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3157721755 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GUTHRIE AHC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
ID Information
ID | Type | State | Issuer | Description | 1730247156 | 01 |   | PARENT BILLING FACILITY GUTHRIE AHC NPI | OTHER |