Basic Information
| Provider Information | |||||||||
| NPI: | 1073529301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUDSON HEADWATERS HEALTH NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3761 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARRENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128851837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186233918 | ||||||||
| FaxNumber: | 5186234330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | TOURNIER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP OF FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 5187610300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUDSON HEADWATERS HEALTH NETWORK | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | NY | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 03289892 | 05 | NY | MEDICAID |