Basic Information
| Provider Information | |||||||||
| NPI: | 1649624941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPSTATE CEREBRAL PALSY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNITED CEREBRAL PALSY, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 MARY ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135011930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157246907 | ||||||||
| FaxNumber: | 3157330791 | ||||||||
| Practice Location | |||||||||
| Address1: | 10708 N GAGE RD | ||||||||
| Address2: | |||||||||
| City: | BARNEVELD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133042527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158962654 | ||||||||
| FaxNumber: | 3158962717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | TEHAN | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3157246907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 6282310 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.