Basic Information
| Provider Information | |||||||||
| NPI: | 1235142472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF NEW YORK COMPTROLLERS OFFICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HELEN HAYES HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | WEST HAVERSTRAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109931127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457864000 | ||||||||
| FaxNumber: | 8459470036 | ||||||||
| Practice Location | |||||||||
| Address1: | ROUTE 9W | ||||||||
| Address2: | |||||||||
| City: | WEST HAVERSTRAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109931127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457864000 | ||||||||
| FaxNumber: | 8459470036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLETTI | ||||||||
| AuthorizedOfficialFirstName: | EDMUND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8457864305 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF NEW YORK COMPTROLLERS OFFICE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 4322000H | NY | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 00273950 | 05 | NY | MEDICAID | 0014119 | 01 | NY | AETNA | OTHER | 00475 | 01 | NY | BLUE CROSS | OTHER | H999014 | 01 | NY | OXFORD | OTHER |