Basic Information
| Provider Information | |||||||||
| NPI: | 1972558179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONIFER PARK, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10092 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122015092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528408 | ||||||||
| FaxNumber: | 5183996860 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 ELM ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187937273 | ||||||||
| FaxNumber: | 5187985004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR, OP BILLING DEPT | ||||||||
| AuthorizedOfficialTelephone: | 5189528408 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 01420800 | 05 | NY | MEDICAID |