Basic Information
Provider Information | |||||||||
NPI: | 1366593410 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEWIS COUNTY GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LEWIS COUNTY HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7785 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | LOWVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 133671229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153765200 | ||||||||
FaxNumber: | 3153769317 | ||||||||
Practice Location | |||||||||
Address1: | 7785 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | LOWVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 133671229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153765200 | ||||||||
FaxNumber: | 3153769317 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 06/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRINCE | ||||||||
AuthorizedOfficialFirstName: | MICHELE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
AuthorizedOfficialTelephone: | 3153765203 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 2424500F | NY | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 01178798 | 05 | NY |   | MEDICAID |