Basic Information
| Provider Information | |||||||||
| NPI: | 1962422733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAYUGA MEDICAL CENTER AT ITHACA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744443 | ||||||||
| FaxNumber: | 6072744527 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744443 | ||||||||
| FaxNumber: | 6072744527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUDD | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6072744443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 5401001H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 365593 | 01 | NY | MVP PROVIDER NO | OTHER | 00332729 | 05 | NY | MEDICAID | 7051 | 01 | NY | TOTAL CARE CLINIC | OTHER | 7300101 | 01 | NY | OPTIMUM CHOICE | OTHER | 284215 | 01 | NY | HEALTHLINK | OTHER | 7051 | 01 | NY | TOTAL CARE URG | OTHER | 908422 | 01 | NY | HARVARD PILGRIM URG CARE | OTHER | 925405 | 01 | NY | CONNECTICARE | OTHER | N49651 | 01 | NY | HEALTHNET CLIN LAB | OTHER | 00011438301 | 01 | NY | UNIVERA PROVIDER NO | OTHER | NY0101 | 01 | NY | JOHN DEERE | OTHER | 7516 | 01 | NY | TOTAL CARE EMERGENCY | OTHER | 5401001H | 01 | NY | NYS PROVIDER/OPER CERT # | OTHER | 900266 | 01 | NY | HARVARD PILGRIM HOSP ED | OTHER | NY7693 | 01 | NY | HEALTHNET HOSP URG CARE | OTHER |