Basic Information
| Provider Information | |||||||||
| NPI: | 1821229139 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERUYTER HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 MAIN ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130456606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 5729 STATE ROUTE 13 | ||||||||
| Address2: | |||||||||
| City: | DERUYTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130520364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158523318 | ||||||||
| FaxNumber: | 3158529997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2009 | ||||||||
| LastUpdateDate: | 08/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | PRIEST | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6077533797 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH NETWORK | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 331863 | 01 | NY | MEDICARE PTAN | OTHER |