Basic Information
| Provider Information | |||||||||
| NPI: | 1366519795 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAYUGA MEDICAL CENTER AT ITHACA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744443 | ||||||||
| FaxNumber: | 6072744527 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744443 | ||||||||
| FaxNumber: | 6072744527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUDD | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 6072744443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 00332729 | 05 | NY | MEDICAID | 365593 | 01 | NY | MVP PROVIDER NO | OTHER | 5401001H | 01 | NY | NYS PROVIDER OPER CERT NO | OTHER | 00011438301 | 01 | NY | UNIVERA PROVIDER NO | OTHER |