Basic Information
| Provider Information | |||||||||
| NPI: | 1326317223 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RAPID CARE - VALATIE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188288051 | ||||||||
| FaxNumber: | 5186973117 | ||||||||
| Practice Location | |||||||||
| Address1: | 2827 US ROUTE 9 | ||||||||
| Address2: | |||||||||
| City: | VALATIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121840785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187584300 | ||||||||
| FaxNumber: | 5187584303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2011 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAHONEY | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5188288249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 1001000H | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 03227290 | 05 | NY | MEDICAID |