Basic Information
| Provider Information | |||||||||
| NPI: | 1720756059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2000 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125342000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4383 ROUTE 23 | ||||||||
| Address2: | |||||||||
| City: | CAIRO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124132680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186973061 | ||||||||
| FaxNumber: | 5186973059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2021 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | MAHONEY | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5188288090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 03227290 | 05 | NY | MEDICAID |