Basic Information
Provider Information | |||||||||
NPI: | 1437491958 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SARATOGA HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GALWAY FAMILY HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3450 | ||||||||
Address2: |   | ||||||||
City: | SARATOGA SPRINGS | ||||||||
State: | NY | ||||||||
PostalCode: | 128668009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5185802030 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5344 SACANDAGA RD | ||||||||
Address2: |   | ||||||||
City: | GALWAY | ||||||||
State: | NY | ||||||||
PostalCode: | 120740190 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188826955 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2013 | ||||||||
LastUpdateDate: | 03/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOSTER | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP&CFO | ||||||||
AuthorizedOfficialTelephone: | 5185838421 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SARATOGA HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 70029A | 01 | NY | MEDICARE PART B | OTHER |