Basic Information
| Provider Information | |||||||||
| NPI: | 1689734147 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLAXTON HEPBURN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153938880 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153938880 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | MOREY | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3153938880 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLAXTON HEPBURN MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4401000H | NY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00577775 | 05 | NY | MEDICAID |