Basic Information
| Provider Information | |||||||||
| NPI: | 1770671448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATHAN LITTAUER HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NATHAN LITTAUER PRIMARY/SPECIALTY CARE CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754205 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754205 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCMAHON | ||||||||
| AuthorizedOfficialFirstName: | PATRICE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT PRIMARY/SPECIAL CARE | ||||||||
| AuthorizedOfficialTelephone: | 5187735728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATHAN LITTAUER HOPITAL AND NURSING HOME | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 1701000H | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00313924 | 05 | NY | MEDICAID |