Basic Information
Provider Information | |||||||||
NPI: | 1497089098 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HUDSON HEADWATERS HEALTH NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 CAREY RD | ||||||||
Address2: |   | ||||||||
City: | QUEENSBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 128047880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187610300 | ||||||||
FaxNumber: | 5188242388 | ||||||||
Practice Location | |||||||||
Address1: | 100 PARK ST | ||||||||
Address2: |   | ||||||||
City: | GLENS FALLS | ||||||||
State: | NY | ||||||||
PostalCode: | 128014413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187610300 | ||||||||
FaxNumber: | 5188242388 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2009 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TOURNIER | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VP OF FINANCE/CFO | ||||||||
AuthorizedOfficialTelephone: | 5187610300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HUDSON HEADWATERS HEALTH NETWORK | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 206339 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
ID | Type | State | Issuer | Description | 02558203 | 05 | NY |   | MEDICAID |