Basic Information
| Provider Information | |||||||||
| NPI: | 1861552549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLAXTON HEPBURN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153938880 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153938880 | ||||||||
| FaxNumber: | 3153937250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLOOM | ||||||||
| AuthorizedOfficialFirstName: | ROB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3157135202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLAXTON HEPBURN MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 4401000H | NY | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 00354072 | 05 | NY | MEDICAID | 029666883 | 05 | NY | MEDICAID |