Basic Information
| Provider Information | |||||||||
| NPI: | 1407907215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PLANNED PARENTHOOD OF THE NORTH COUNTRY NEW YORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PLANNED PARENTHOOD OF NORTHERN NEW YORK, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 160 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157888065 | ||||||||
| FaxNumber: | 3152227432 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157888065 | ||||||||
| FaxNumber: | 3152227432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLECK | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5855462771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 2201201R | NY | N | Agencies | Case Management | 261QA0005X | 2201201R | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Family Planning Facility | 261QA0005X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Family Planning Facility |
ID Information
| ID | Type | State | Issuer | Description | 01062844 | 05 | NY | MEDICAID | 00583697 | 05 | NY | MEDICAID |