Provider Demographics
NPI:1417127721
Name:FAXTON ST LUKES HEALTHCARE
Entity Type:Organization
Organization Name:FAXTON ST LUKES HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-801-4429
Mailing Address - Street 1:2209 GENESEE ST/ BUSINESS OFFICE
Mailing Address - Street 2:ROOM #315
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5809
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-824-2513
Practice Address - Street 1:10 EATON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346
Practice Address - Country:US
Practice Address - Phone:315-824-2639
Practice Address - Fax:315-824-2513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAXTON ST LUKES HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-04
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3202003H261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY333567Medicare Oscar/Certification