Basic Information
| Provider Information | |||||||||
| NPI: | 1710233861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JEFFERSON HEIGHTS FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188288051 | ||||||||
| FaxNumber: | 5186973117 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 JEFFERSON HTS | ||||||||
| Address2: | SUITE D-201 | ||||||||
| City: | CATSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189433415 | ||||||||
| FaxNumber: | 5189430938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2012 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAHONEY | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5188288090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 |