Basic Information
Provider Information | |||||||||
NPI: | 1528314648 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNTAIN VIEW MEDICAL PRACTICE (CATSKILL) | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2000 | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | NY | ||||||||
PostalCode: | 125342000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188288363 | ||||||||
FaxNumber: | 5186973388 | ||||||||
Practice Location | |||||||||
Address1: | 159 JEFFERSON HTS | ||||||||
Address2: | SUITE C-201 | ||||||||
City: | CATSKILL | ||||||||
State: | NY | ||||||||
PostalCode: | 124141237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5189431943 | ||||||||
FaxNumber: | 5189431510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2012 | ||||||||
LastUpdateDate: | 07/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DINGMAN | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5188288249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 1001000H | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | W79533 | 01 | NY | MEDICARE GROUP | OTHER |