Basic Information
| Provider Information | |||||||||
| NPI: | 1518112077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESSEX COUNTY PUBLIC HEALTH NURSING SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 WATER STREET | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129320217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188733500 | ||||||||
| FaxNumber: | 5188733539 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 WATER ST. | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129320217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188733500 | ||||||||
| FaxNumber: | 5188733539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2008 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | KNOX | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | DANA | ||||||||
| AuthorizedOfficialTitleorPosition: | FISCAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5188733503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | 03084017 | 05 | NY | MEDICAID |