Provider Demographics
NPI:1083899702
Name:STATE OF NEW YORK
Entity Type:Organization
Organization Name:STATE OF NEW YORK
Other - Org Name:CAH SUNMOUNT DDSO
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CENTRAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-402-4333
Mailing Address - Street 1:44 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12229-0001
Mailing Address - Country:US
Mailing Address - Phone:518-402-4333
Mailing Address - Fax:
Practice Address - Street 1:2445 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-2502
Practice Address - Country:US
Practice Address - Phone:518-457-9835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW YORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-31
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCAH00018251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01361182Medicaid