Basic Information
| Provider Information | |||||||||
| NPI: | 1700198652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY IMOGENE BASSETT HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BASSETT HEALTHCARE NETWORK LITTLE FALLS DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473456 | ||||||||
| FaxNumber: | 6075476325 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 BURWELL ST | ||||||||
| Address2: | |||||||||
| City: | LITTLE FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133651725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473350 | ||||||||
| FaxNumber: | 6075473467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SWINKO | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6075473096 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00305000 | 05 | NY | MEDICAID |