Basic Information
Provider Information | |||||||||
NPI: | 1780052514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VASSAR BROTHERS MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VASSAR DIAGNOSTICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45 READE PL | ||||||||
Address2: |   | ||||||||
City: | POUGHKEEPSIE | ||||||||
State: | NY | ||||||||
PostalCode: | 126013947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454548500 | ||||||||
FaxNumber: | 8454759915 | ||||||||
Practice Location | |||||||||
Address1: | 45 READE PL | ||||||||
Address2: |   | ||||||||
City: | POUGHKEEPSIE | ||||||||
State: | NY | ||||||||
PostalCode: | 126013947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454548500 | ||||||||
FaxNumber: | 8454759915 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2015 | ||||||||
LastUpdateDate: | 04/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEHRBOM | ||||||||
AuthorizedOfficialFirstName: | MARIE | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8454759946 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 1302001H | NY | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 103527 | 01 |   | WELLCARE | OTHER | HO5540 | 01 |   | OXFORD | OTHER | 00273854 | 05 | NY |   | MEDICAID | 3527 | 01 |   | GHI | OTHER | 70026 | 01 |   | MVP | OTHER | 10019452 | 01 |   | CDPHP | OTHER | 00206 | 01 |   | BLUE CROSS | OTHER |