Provider Demographics
NPI:1144755596
Name:COLUMBIA MEMORIAL HEALTH
Entity Type:Organization
Organization Name:COLUMBIA MEMORIAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLANAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:585-764-0154
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MUMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14511-0428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-828-7601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020746-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty