Basic Information
| Provider Information | |||||||||
| NPI: | 1487644993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLIS HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MCCLELLAN ST | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123041009 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 NOTT ST | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182434000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILTON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5182434141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4601001H | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000400009000 | 01 | NY | BSNENY | OTHER | 00347562 | 05 | NY | MEDICAID | 000009 | 01 | NY | EMPIRE BLUE CROSS | OTHER | 0101 | 01 | NY | MVP | OTHER | 10005801 | 01 | NY | CDPHP | OTHER |