Basic Information
Provider Information | |||||||||
NPI: | 1861437832 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAMARITAN HOSPITAL OF TROY, NEW YORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAMARITAN BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14890 | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122124890 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2215 BURDETT AVE | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | NY | ||||||||
PostalCode: | 12180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182713300 | ||||||||
FaxNumber: | 5184713254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 03/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KNOWLES | ||||||||
AuthorizedOfficialFirstName: | COURTNEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5185255634 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SAMARITAN HOSPITAL OF TROY, NEW YORK | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4102002H |   | N |   | Hospitals | General Acute Care Hospital |   | 251B00000X |   |   | N |   | Agencies | Case Management |   | 273R00000X | 4102002H | NY | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 00318805 | 05 | NY |   | MEDICAID |