Basic Information
| Provider Information | |||||||||
| NPI: | 1760800635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENS FALLS HOSPITAL INC. | ||||||||
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| OtherOrganizationName: | EMERGENCY CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | EMERGENCY CARE CENTER | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266992 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | EMERGENCY CARE CENTER | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266992 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | AMADO | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5189265113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GLENS FALLS HOSPITAL INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 70021A | 01 | NY | MEDICARE PART B | OTHER |