Basic Information
| Provider Information | |||||||||
| NPI: | 1760614317 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELLIS HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MCCLELLAN ST | ||||||||
| Address2: | 2 WEST | ||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123041009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183475400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 NOTT ST | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182434000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILTON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5182434141 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELLIS HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207R00000X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2080N0001X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2084P0800X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208M00000X | 4601001H | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03177066 | 05 | NY | MEDICAID |