Basic Information
| Provider Information | |||||||||
| NPI: | 1659758928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SARATOGA HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARDIOLOGY-MALTA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120205051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188865080 | ||||||||
| FaxNumber: | 5188865805 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | MALTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120205051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188865080 | ||||||||
| FaxNumber: | 5188865805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5185838421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SARATOGA HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 03849694 | 05 | NY | MEDICAID |