Provider Demographics
NPI:1265459945
Name:CROUSE HEALTH INC.
Entity Type:Organization
Organization Name:CROUSE HEALTH INC.
Other - Org Name:COMMONWEALTH PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-470-7376
Mailing Address - Street 1:736 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1687
Mailing Address - Country:US
Mailing Address - Phone:315-470-2470
Mailing Address - Fax:
Practice Address - Street 1:6010 E MOLLOY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13211-2131
Practice Address - Country:US
Practice Address - Phone:315-470-2470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROUSE HEALTH HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04105361324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158709Medicaid