Provider Demographics
NPI:1033361340
Name:ST LUKE'S CORNWALL HOSPITAL
Entity Type:Organization
Organization Name:ST LUKE'S CORNWALL HOSPITAL
Other - Org Name:FACULTY GROUP PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-458-4023
Mailing Address - Street 1:21 LAUREL AVE STE 240
Mailing Address - Street 2:FACULTY GROUP PRACTICE ST LUKE'S CORNWALL HOSPITAL
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1476
Mailing Address - Country:US
Mailing Address - Phone:845-458-4876
Mailing Address - Fax:845-458-4560
Practice Address - Street 1:21 LAUREL AVE STE 240
Practice Address - Street 2:FACULTY GROUP PRACTICE ST LUKE'S CORNWALL HOSPITAL
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1476
Practice Address - Country:US
Practice Address - Phone:845-458-4876
Practice Address - Fax:845-458-4560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKE'S CORNWALL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-17
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03121666Medicaid
NYA100001031Medicare PIN