Basic Information
Provider Information
NPI: 1871989871
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HUDAK
FirstName: GRACE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 140 OLD ORANGEBURG RD
Address2:  
City: ORANGEBURG
State: NY
PostalCode: 109621157
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 140 OLD ORANGEBURG RD
Address2:  
City: ORANGEBURG
State: NY
PostalCode: 109621157
CountryCode: US
TelephoneNumber: 8453591000
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/07/2015
LastUpdateDate: 04/07/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
283Q00000X260927NYY HospitalsPsychiatric Hospital 

No ID Information.


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