Basic Information
| Provider Information | |||||||||
| NPI: | 1316008311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPSTATE CEREBRAL PALSY, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1020 MARY ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135011930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157246907 | ||||||||
| FaxNumber: | 3157330791 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 BROOKLEY ROAD | ||||||||
| Address2: | CRP #7 | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155331166 | ||||||||
| FaxNumber: | 3155331165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DECONDO | ||||||||
| AuthorizedOfficialFirstName: | GENO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157246907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 02708809 | NY | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 02708809 | 05 | NY | MEDICAID |