Provider Demographics
NPI:1063442192
Name:ST JOSEPH'S HOSPITAL HEALTH CENTER
Entity Type:Organization
Organization Name:ST JOSEPH'S HOSPITAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FISCAL AFFAIRS
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-448-5880
Mailing Address - Street 1:301 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-448-5880
Mailing Address - Fax:315-448-6161
Practice Address - Street 1:8136 OSWEGO STREET
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02995893Medicaid
NY00315013Medicaid
NY02995893Medicaid
NY333510Medicare ID - Type UnspecifiedPROVIDER #