Basic Information
| Provider Information | |||||||||
| NPI: | 1154343168 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 5184800108 | ||||||||
| Practice Location | |||||||||
| Address1: | MAIN STREET AND PELON ROAD | ||||||||
| Address2: | |||||||||
| City: | INDIAN LAKE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128420684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186485707 | ||||||||
| FaxNumber: | 5186486160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | TOURNIER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5187610300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUDSON HEADWATERS HEALTH NETWORK | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6846 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.