Provider Demographics
NPI:1164637112
Name:GUTHRIE AHC
Entity Type:Organization
Organization Name:GUTHRIE AHC
Other - Org Name:OHC-WATERVLIET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING UBO MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-772-1755
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:UBO
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-4033
Mailing Address - Fax:
Practice Address - Street 1:10205 N RIVA RIDGE LOOP
Practice Address - Street 2:SUITE P36
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5457
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUTHRIE AHC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-13
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN
VAD000Medicare UPIN