Basic Information
| Provider Information | |||||||||
| NPI: | 1417540824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA MEMORIAL REGIONAL MEDICAL PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CMH-LAFAYETTE FAMILY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188288051 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 LAFAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | COXSACKIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120511305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187317770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAHONEY | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5188288090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 03227290 | 05 | NY | MEDICAID |