Basic Information
| Provider Information | |||||||||
| NPI: | 1790857308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEWIS COUNTY GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
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| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157015610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9559 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BEAVER FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153466824 | ||||||||
| FaxNumber: | 3153466868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | PRINCE | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3153765226 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02848213 | 05 | NY | MEDICAID |