Basic Information
| Provider Information | |||||||||
| NPI: | 1679503544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SARATOGA HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 211 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128661046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185873222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128661046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185873222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER-INTERIM | ||||||||
| AuthorizedOfficialTelephone: | 5185838421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4501000N | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000400024002 | 01 | NY | BLUE SHIELD OF NORTHEASTE | OTHER | 00336874 | 05 | NY | MEDICAID |