Provider Demographics
NPI:1073534046
Name:CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
Other - Org Name:CHAMPLAIN VALLEY PHYSICIANS MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-562-7055
Mailing Address - Street 1:75 BEEKMAN ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1438
Mailing Address - Country:US
Mailing Address - Phone:518-562-7557
Mailing Address - Fax:518-562-7183
Practice Address - Street 1:214 CORNELIA ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2317
Practice Address - Country:US
Practice Address - Phone:518-562-7155
Practice Address - Fax:518-562-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0117723336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063511OtherPK
NY00318814Medicaid