Basic Information
| Provider Information | |||||||||
| NPI: | 1114104445 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANTON-POTSDAM HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LEROY STREET | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152655745 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 LEROY STREET | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152655745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGREGOR | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3152615451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 4429000H | 05 | NY | MEDICAID |