Basic Information
| Provider Information | |||||||||
| NPI: | 1265484489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHALLIANCE HOSPITAL BROADWAY CAMPUS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE KINGSTON HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 396 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313131 | ||||||||
| FaxNumber: | 8459436077 | ||||||||
| Practice Location | |||||||||
| Address1: | 396 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313131 | ||||||||
| FaxNumber: | 8459436077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARSICOVETE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8453342750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00274048 | 05 | NY | MEDICAID |