Provider Demographics
NPI:1164998423
Name:HUDSON HEADWATERS HEALTH NETWORK
Entity Type:Organization
Organization Name:HUDSON HEADWATERS HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-761-0300
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:87 PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6438
Practice Address - Country:US
Practice Address - Phone:518-536-7060
Practice Address - Fax:518-536-7075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUDSON HEADWATERS HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-15
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05550376Medicaid