Basic Information
| Provider Information | |||||||||
| NPI: | 1720374093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPSTATE CEREBRAL PALSY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UPSTATE CEREBRAL PALSY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 336 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | HERKIMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158662839 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | DECON DO | ||||||||
| AuthorizedOfficialFirstName: | GENO | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157246907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 02146303 | 05 | NY | MEDICAID |