Basic Information
| Provider Information | |||||||||
| NPI: | 1386639771 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | KAATERSKILL CARE NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 PROSPECT AVE | ||||||||
| Address2: | P O BOX 2000 | ||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188288363 | ||||||||
| FaxNumber: | 5186973388 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 JEFFERSON HTS | ||||||||
| Address2: | |||||||||
| City: | CATSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124141239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186973258 | ||||||||
| FaxNumber: | 5186973041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | SIEDSMA | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 5188288099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1001000N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 01050513 | 05 | NY | MEDICAID |